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

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

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

PubMed

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

2014-01-01

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

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.

Quantization error of CCD cameras and their influence on phase calculation in fringe pattern analysis.

PubMed

Skydan, Oleksandr A; Lilley, Francis; Lalor, Michael J; Burton, David R

2003-09-10

We present an investigation into the phase errors that occur in fringe pattern analysis that are caused by quantization effects. When acquisition devices with a limited value of camera bit depth are used, there are a limited number of quantization levels available to record the signal. This may adversely affect the recorded signal and adds a potential source of instrumental error to the measurement system. Quantization effects also determine the accuracy that may be achieved by acquisition devices in a measurement system. We used the Fourier fringe analysis measurement technique. However, the principles can be applied equally well for other phase measuring techniques to yield a phase error distribution that is caused by the camera bit depth.

Simulation: learning from mistakes while building communication and teamwork.

PubMed

Kuehster, Christina R; Hall, Carla D

2010-01-01

Medical errors are one of the leading causes of death annually in the United States. Many of these errors are related to poor communication and/or lack of teamwork. Using simulation as a teaching modality provides a dual role in helping to reduce these errors. Thorough integration of clinical practice with teamwork and communication in a safe environment increases the likelihood of reducing the error rates in medicine. By allowing practitioners to make potential errors in a safe environment, such as simulation, these valuable lessons improve retention and will rarely be repeated.

[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.

Diagnostic Error in Correctional Mental Health: Prevalence, Causes, and Consequences.

PubMed

Martin, Michael S; Hynes, Katie; Hatcher, Simon; Colman, Ian

2016-04-01

While they have important implications for inmates and resourcing of correctional institutions, diagnostic errors are rarely discussed in correctional mental health research. This review seeks to estimate the prevalence of diagnostic errors in prisons and jails and explores potential causes and consequences. Diagnostic errors are defined as discrepancies in an inmate's diagnostic status depending on who is responsible for conducting the assessment and/or the methods used. It is estimated that at least 10% to 15% of all inmates may be incorrectly classified in terms of the presence or absence of a mental illness. Inmate characteristics, relationships with staff, and cognitive errors stemming from the use of heuristics when faced with time constraints are discussed as possible sources of error. A policy example of screening for mental illness at intake to prison is used to illustrate when the risk of diagnostic error might be increased and to explore strategies to mitigate this risk. © The Author(s) 2016.

Medication Incidents Involving Antiepileptic Drugs in Canadian Hospitals: A Multi-Incident Analysis.

PubMed

Cheng, Roger; Yang, Yu Daisy; Chan, Matthew; Patel, Tejal

2017-01-01

Medication errors involving antiepileptic drugs (AEDs) are not well studied but have the potential to cause significant harm. We investigated the occurrence of medication incidents in Canadian hospitals that involve AEDs, their severity and contributing factors by analyzing data from two national databases. Our multi-incident analysis revealed that while medication errors were rarely fatal, errors do occur of which some are serious. Medication incidents were most commonly caused by dose omissions, the dose or its frequency being incorrect and the wrong AED being given. Our analysis could augment quality-improvement initiatives by medication safety administrators to reduce AED medication incidents in hospitals.

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.

Good people who try their best can have problems: recognition of human factors and how to minimise error.

PubMed

Brennan, Peter A; Mitchell, David A; Holmes, Simon; Plint, Simon; Parry, David

2016-01-01

Human error is as old as humanity itself and is an appreciable cause of mistakes by both organisations and people. Much of the work related to human factors in causing error has originated from aviation where mistakes can be catastrophic not only for those who contribute to the error, but for passengers as well. The role of human error in medical and surgical incidents, which are often multifactorial, is becoming better understood, and includes both organisational issues (by the employer) and potential human factors (at a personal level). Mistakes as a result of individual human factors and surgical teams should be better recognised and emphasised. Attitudes and acceptance of preoperative briefing has improved since the introduction of the World Health Organization (WHO) surgical checklist. However, this does not address limitations or other safety concerns that are related to performance, such as stress and fatigue, emotional state, hunger, awareness of what is going on situational awareness, and other factors that could potentially lead to error. Here we attempt to raise awareness of these human factors, and highlight how they can lead to error, and how they can be minimised in our day-to-day practice. Can hospitals move from being "high risk industries" to "high reliability organisations"? Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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

PubMed

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

2016-06-01

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

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.

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

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

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.

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

Nagayama, T.; Bailey, J. E.; Loisel, G. P.

Iron opacity calculations presently disagree with measurements at an electron temperature of ~180–195 eV and an electron density of (2–4)×10 22cm –3, conditions similar to those at the base of the solar convection zone. The measurements use x rays to volumetrically heat a thin iron sample that is tamped with low-Z materials. The opacity is inferred from spectrally resolved x-ray transmission measurements. Plasma self-emission, tamper attenuation, and temporal and spatial gradients can all potentially cause systematic errors in the measured opacity spectra. In this article we quantitatively evaluate these potential errors with numerical investigations. The analysis exploits computer simulations thatmore » were previously found to reproduce the experimentally measured plasma conditions. The simulations, combined with a spectral synthesis model, enable evaluations of individual and combined potential errors in order to estimate their potential effects on the opacity measurement. Lastly, the results show that the errors considered here do not account for the previously observed model-data discrepancies.« less

Distortion of Digital Image Correlation (DIC) Displacements and Strains from Heat Waves

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

Jones, E. M. C.; Reu, P. L.

“Heat waves” is a colloquial term used to describe convective currents in air formed when different objects in an area are at different temperatures. In the context of Digital Image Correlation (DIC) and other optical-based image processing techniques, imaging an object of interest through heat waves can significantly distort the apparent location and shape of the object. We present that there are many potential heat sources in DIC experiments, including but not limited to lights, cameras, hot ovens, and sunlight, yet error caused by heat waves is often overlooked. This paper first briefly presents three practical situations in which heatmore » waves contributed significant error to DIC measurements to motivate the investigation of heat waves in more detail. Then the theoretical background of how light is refracted through heat waves is presented, and the effects of heat waves on displacements and strains computed from DIC are characterized in detail. Finally, different filtering methods are investigated to reduce the displacement and strain errors caused by imaging through heat waves. The overarching conclusions from this work are that errors caused by heat waves are significantly higher than typical noise floors for DIC measurements, and that the errors are difficult to filter because the temporal and spatial frequencies of the errors are in the same range as those of typical signals of interest. In conclusion, eliminating or mitigating the effects of heat sources in a DIC experiment is the best solution to minimizing errors caused by heat waves.« less

Distortion of Digital Image Correlation (DIC) Displacements and Strains from Heat Waves

DOE PAGES

Jones, E. M. C.; Reu, P. L.

2017-11-28

“Heat waves” is a colloquial term used to describe convective currents in air formed when different objects in an area are at different temperatures. In the context of Digital Image Correlation (DIC) and other optical-based image processing techniques, imaging an object of interest through heat waves can significantly distort the apparent location and shape of the object. We present that there are many potential heat sources in DIC experiments, including but not limited to lights, cameras, hot ovens, and sunlight, yet error caused by heat waves is often overlooked. This paper first briefly presents three practical situations in which heatmore » waves contributed significant error to DIC measurements to motivate the investigation of heat waves in more detail. Then the theoretical background of how light is refracted through heat waves is presented, and the effects of heat waves on displacements and strains computed from DIC are characterized in detail. Finally, different filtering methods are investigated to reduce the displacement and strain errors caused by imaging through heat waves. The overarching conclusions from this work are that errors caused by heat waves are significantly higher than typical noise floors for DIC measurements, and that the errors are difficult to filter because the temporal and spatial frequencies of the errors are in the same range as those of typical signals of interest. In conclusion, eliminating or mitigating the effects of heat sources in a DIC experiment is the best solution to minimizing errors caused by heat waves.« less

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

PubMed

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

2009-01-01

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

Fluorescence errors in integrating sphere measurements of remote phosphor type LED light sources

NASA Astrophysics Data System (ADS)

Keppens, A.; Zong, Y.; Podobedov, V. B.; Nadal, M. E.; Hanselaer, P.; Ohno, Y.

2011-05-01

The relative spectral radiant flux error caused by phosphor fluorescence during integrating sphere measurements is investigated both theoretically and experimentally. Integrating sphere and goniophotometer measurements are compared and used for model validation, while a case study provides additional clarification. Criteria for reducing fluorescence errors to a degree of negligibility as well as a fluorescence error correction method based on simple matrix algebra are presented. Only remote phosphor type LED light sources are studied because of their large phosphor surfaces and high application potential in general lighting.

Attitudes of Mashhad Public Hospital's Nurses and Midwives toward the Causes and Rates of Medical Errors Reporting.

PubMed

Mobarakabadi, Sedigheh Sedigh; Ebrahimipour, Hosein; Najar, Ali Vafaie; Janghorban, Roksana; Azarkish, Fatemeh

2017-03-01

Patient's safety is one of the main objective in healthcare services; however medical errors are a prevalent potential occurrence for the patients in treatment systems. Medical errors lead to an increase in mortality rate of the patients and challenges such as prolonging of the inpatient period in the hospitals and increased cost. Controlling the medical errors is very important, because these errors besides being costly, threaten the patient's safety. To evaluate the attitudes of nurses and midwives toward the causes and rates of medical errors reporting. It was a cross-sectional observational study. The study population was 140 midwives and nurses employed in Mashhad Public Hospitals. The data collection was done through Goldstone 2001 revised questionnaire. SPSS 11.5 software was used for data analysis. To analyze data, descriptive and inferential analytic statistics were used. Standard deviation and relative frequency distribution, descriptive statistics were used for calculation of the mean and the results were adjusted as tables and charts. Chi-square test was used for the inferential analysis of the data. Most of midwives and nurses (39.4%) were in age range of 25 to 34 years and the lowest percentage (2.2%) were in age range of 55-59 years. The highest average of medical errors was related to employees with three-four years of work experience, while the lowest average was related to those with one-two years of work experience. The highest average of medical errors was during the evening shift, while the lowest were during the night shift. Three main causes of medical errors were considered: illegibile physician prescription orders, similarity of names in different drugs and nurse fatigueness. The most important causes for medical errors from the viewpoints of nurses and midwives are illegible physician's order, drug name similarity with other drugs, nurse's fatigueness and damaged label or packaging of the drug, respectively. Head nurse feedback, peer feedback, fear of punishment or job loss were considered as reasons for under reporting of medical errors. This research demonstrates the need for greater attention to be paid to the causes of medical errors.

Evaluation of causes and frequency of medication errors during information technology downtime.

PubMed

Hanuscak, Tara L; Szeinbach, Sheryl L; Seoane-Vazquez, Enrique; Reichert, Brendan J; McCluskey, Charles F

2009-06-15

The causes and frequency of medication errors occurring during information technology downtime were evaluated. Individuals from a convenience sample of 78 hospitals who were directly responsible for supporting and maintaining clinical information systems (CISs) and automated dispensing systems (ADSs) were surveyed using an online tool between February 2007 and May 2007 to determine if medication errors were reported during periods of system downtime. The errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention severity scoring index. The percentage of respondents reporting downtime was estimated. Of the 78 eligible hospitals, 32 respondents with CIS and ADS responsibilities completed the online survey for a response rate of 41%. For computerized prescriber order entry, patch installations and system upgrades caused an average downtime of 57% over a 12-month period. Lost interface and interface malfunction were reported for centralized and decentralized ADSs, with an average downtime response of 34% and 29%, respectively. The average downtime response was 31% for software malfunctions linked to clinical decision-support systems. Although patient harm did not result from 30 (54%) medication errors, the potential for harm was present for 9 (16%) of these errors. Medication errors occurred during CIS and ADS downtime despite the availability of backup systems and standard protocols to handle periods of system downtime. Efforts should be directed to reduce the frequency and length of down-time in order to minimize medication errors during such downtime.

Numerical investigations of potential systematic uncertainties in iron opacity measurements at solar interior temperatures

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

Nagayama, T.; Bailey, J. E.; Loisel, G. P.

Iron opacity calculations presently disagree with measurements at an electron temperature of ~180–195 eV and an electron density of (2–4)×10 22cm –3, conditions similar to those at the base of the solar convection zone. The measurements use x rays to volumetrically heat a thin iron sample that is tamped with low-Z materials. The opacity is inferred from spectrally resolved x-ray transmission measurements. Plasma self-emission, tamper attenuation, and temporal and spatial gradients can all potentially cause systematic errors in the measured opacity spectra. In this article we quantitatively evaluate these potential errors with numerical investigations. The analysis exploits computer simulations thatmore » were previously found to reproduce the experimentally measured plasma conditions. The simulations, combined with a spectral synthesis model, enable evaluations of individual and combined potential errors in order to estimate their potential effects on the opacity measurement. Lastly, the results show that the errors considered here do not account for the previously observed model-data discrepancies.« less

Numerical investigations of potential systematic uncertainties in iron opacity measurements at solar interior temperatures

DOE PAGES

Nagayama, T.; Bailey, J. E.; Loisel, G. P.; ...

2017-06-26

Iron opacity calculations presently disagree with measurements at an electron temperature of ~180–195 eV and an electron density of (2–4)×10 22cm –3, conditions similar to those at the base of the solar convection zone. The measurements use x rays to volumetrically heat a thin iron sample that is tamped with low-Z materials. The opacity is inferred from spectrally resolved x-ray transmission measurements. Plasma self-emission, tamper attenuation, and temporal and spatial gradients can all potentially cause systematic errors in the measured opacity spectra. In this article we quantitatively evaluate these potential errors with numerical investigations. The analysis exploits computer simulations thatmore » were previously found to reproduce the experimentally measured plasma conditions. The simulations, combined with a spectral synthesis model, enable evaluations of individual and combined potential errors in order to estimate their potential effects on the opacity measurement. Lastly, the results show that the errors considered here do not account for the previously observed model-data discrepancies.« less

Interspecific song imitation by a Prairie Warbler

Treesearch

Bruce E. Byers; Brodie A. Kramer; Michael E. Akresh; David I. King

2013-01-01

Song development in oscine songbirds relies on imitation of adult singers and thus leaves developing birds vulnerable to potentially costly errors caused by imitation of inappropriate models, such as the songs of other species. In May and June 2012, we recorded the songs of a bird that made such an error: a male Prairie Warbler (Setophaga discolor)...

[Application of root cause analysis in healthcare].

PubMed

Hsu, Tsung-Fu

2007-12-01

The main purpose of this study was to explore various aspects of root cause analysis (RCA), including its definition, rationale concept, main objective, implementation procedures, most common analysis methodology (fault tree analysis, FTA), and advantages and methodologic limitations in regard to healthcare. Several adverse events that occurred at a certain hospital were also analyzed by the author using FTA as part of this study. RCA is a process employed to identify basic and contributing causal factors underlying performance variations associated with adverse events. The rationale concept of RCA offers a systemic approach to improving patient safety that does not assign blame or liability to individuals. The four-step process involved in conducting an RCA includes: RCA preparation, proximate cause identification, root cause identification, and recommendation generation and implementation. FTA is a logical, structured process that can help identify potential causes of system failure before actual failures occur. Some advantages and significant methodologic limitations of RCA were discussed. Finally, we emphasized that errors stem principally from faults attributable to system design, practice guidelines, work conditions, and other human factors, which induce health professionals to make negligence or mistakes with regard to healthcare. We must explore the root causes of medical errors to eliminate potential RCA system failure factors. Also, a systemic approach is needed to resolve medical errors and move beyond a current culture centered on assigning fault to individuals. In constructing a real environment of patient-centered safety healthcare, we can help encourage clients to accept state-of-the-art healthcare services.

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

PubMed

Hatcher, Irene; Sullivan, Mark; Hutchinson, James; Thurman, Susan; Gaffney, F Andrew

2004-10-01

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

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.

[Failure modes and effects analysis in the prescription, validation and dispensing process].

PubMed

Delgado Silveira, E; Alvarez Díaz, A; Pérez Menéndez-Conde, C; Serna Pérez, J; Rodríguez Sagrado, M A; Bermejo Vicedo, T

2012-01-01

To apply a failure modes and effects analysis to the prescription, validation and dispensing process for hospitalised patients. A work group analysed all of the stages included in the process from prescription to dispensing, identifying the most critical errors and establishing potential failure modes which could produce a mistake. The possible causes, their potential effects, and the existing control systems were analysed to try and stop them from developing. The Hazard Score was calculated, choosing those that were ≥ 8, and a Severity Index = 4 was selected independently of the hazard Score value. Corrective measures and an implementation plan were proposed. A flow diagram that describes the whole process was obtained. A risk analysis was conducted of the chosen critical points, indicating: failure mode, cause, effect, severity, probability, Hazard Score, suggested preventative measure and strategy to achieve so. Failure modes chosen: Prescription on the nurse's form; progress or treatment order (paper); Prescription to incorrect patient; Transcription error by nursing staff and pharmacist; Error preparing the trolley. By applying a failure modes and effects analysis to the prescription, validation and dispensing process, we have been able to identify critical aspects, the stages in which errors may occur and the causes. It has allowed us to analyse the effects on the safety of the process, and establish measures to prevent or reduce them. Copyright © 2010 SEFH. Published by Elsevier Espana. All rights reserved.

Physicians and pharmacists: collaboration to improve the quality of prescriptions in primary care in Mexico.

PubMed

Mino-León, Dolores; Reyes-Morales, Hortensia; Jasso, Luis; Douvoba, Svetlana Vladislavovna

2012-06-01

Inappropriate prescription is a relevant problem in primary health care settings in Mexico, with potentially harmful consequences for patients. To evaluate the effectiveness of incorporating a pharmacist into primary care health team to reduce prescription errors for patients with diabetes and/or hypertension. One Family Medicine Clinic from the Mexican Institute of Social Security in Mexico City. A "pharmacotherapy intervention" provided by pharmacists through a quasi experimental (before-after) design was carried out. Physicians who allowed access to their diabetes and/or hypertensive patients' medical records and prescriptions were included in the study. Prescription errors were classified as "filling", "clinical" or "both". Descriptive analysis, identification of potential drug-drug interactions (pD-DI), and comparison of the proportion of patients with prescriptions with errors detected "before" and "after" intervention were performed. Decrease in the proportion of patients who received prescriptions with errors after the intervention. Pharmacists detected at least one type of error in 79 out of 160 patients. Errors were "clinical", "both" and "filling" in 47, 21 and 11 of these patient's prescriptions respectively. Predominant errors were, in the subgroup of patient's prescriptions with "clinical" errors, pD-DI; in the subgroup of "both" errors, lack of information on dosing interval and pD-DI; and in the "filling" subgroup, lack of information on dosing interval. The pD-DI caused 50 % of the errors detected, from which 19 % were of major severity. The impact of the correction of errors post-intervention was observed in 19 % of patients who had erroneous prescriptions before the intervention of the pharmacist (49.3-30.3 %, p < 0.05). The impact of the intervention was relevant from a clinical point of view for the public health services in Mexico. The implementation of early warning systems of the most widely prescribed drugs is an alternative for reducing prescription errors and consequently the risks they may cause.

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

[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.

Factors correlated with traffic accidents as a basis for evaluating Advanced Driver Assistance Systems.

PubMed

Staubach, Maria

2009-09-01

This study aims to identify factors which influence and cause errors in traffic accidents and to use these as a basis for information to guide the application and design of driver assistance systems. A total of 474 accidents were examined in depth for this study by means of a psychological survey, data from accident reports, and technical reconstruction information. An error analysis was subsequently carried out, taking into account the driver, environment, and vehicle sub-systems. Results showed that all accidents were influenced by errors as a consequence of distraction and reduced activity. For crossroad accidents, there were further errors resulting from sight obstruction, masked stimuli, focus errors, and law infringements. Lane departure crashes were additionally caused by errors as a result of masked stimuli, law infringements, expectation errors as well as objective and action slips, while same direction accidents occurred additionally because of focus errors, expectation errors, and objective and action slips. Most accidents were influenced by multiple factors. There is a safety potential for Advanced Driver Assistance Systems (ADAS), which support the driver in information assimilation and help to avoid distraction and reduced activity. The design of the ADAS is dependent on the specific influencing factors of the accident type.

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.

Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence.

PubMed

Keers, Richard N; Williams, Steven D; Cooke, Jonathan; Ashcroft, Darren M

2013-11-01

Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence. This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings. Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013. Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail. A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason's model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used. Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of quantitative surveys and observation methods in many studies, limited use of established error causation frameworks to analyse data and a predominant focus on issues other than the causes of MAEs among studies. As only English language publications were included, some relevant studies may have been missed. Limited evidence from studies included in this systematic review suggests that MAEs are influenced by multiple systems factors, but if and how these arise and interconnect to lead to errors remains to be fully determined. Further research with a theoretical focus is needed to investigate the MAE causation pathway, with an emphasis on ensuring interventions designed to minimise MAEs target recognised underlying causes of errors to maximise their impact.

Investigation on coupling error characteristics in angular rate matching based ship deformation measurement approach

NASA Astrophysics Data System (ADS)

Yang, Shuai; Wu, Wei; Wang, Xingshu; Xu, Zhiguang

2018-01-01

The coupling error in the measurement of ship hull deformation can significantly influence the attitude accuracy of the shipborne weapons and equipments. It is therefore important to study the characteristics of the coupling error. In this paper, an comprehensive investigation on the coupling error is reported, which has a potential of deducting the coupling error in the future. Firstly, the causes and characteristics of the coupling error are analyzed theoretically based on the basic theory of measuring ship deformation. Then, simulations are conducted for verifying the correctness of the theoretical analysis. Simulation results show that the cross-correlation between dynamic flexure and ship angular motion leads to the coupling error in measuring ship deformation, and coupling error increases with the correlation value between them. All the simulation results coincide with the theoretical analysis.

Identification of priorities for medication safety in neonatal intensive care.

PubMed

Kunac, Desireé L; Reith, David M

2005-01-01

Although neonates are reported to be at greater risk of medication error than infants and older children, little is known about the causes and characteristics of error in this patient group. Failure mode and effects analysis (FMEA) is a technique used in industry to evaluate system safety and identify potential hazards in advance. The aim of this study was to identify and prioritize potential failures in the neonatal intensive care unit (NICU) medication use process through application of FMEA. Using the FMEA framework and a systems-based approach, an eight-member multidisciplinary panel worked as a team to create a flow diagram of the neonatal unit medication use process. Then by brainstorming, the panel identified all potential failures, their causes and their effects at each step in the process. Each panel member independently rated failures based on occurrence, severity and likelihood of detection to allow calculation of a risk priority score (RPS). The panel identified 72 failures, with 193 associated causes and effects. Vulnerabilities were found to be distributed across the entire process, but multiple failures and associated causes were possible when prescribing the medication and when preparing the drug for administration. The top ranking issue was a perceived lack of awareness of medication safety issues (RPS score 273), due to a lack of medication safety training. The next highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration. Perceived causes were multiple, but were largely associated with unsafe systems for medication preparation and storage in the unit, variable staff skill level and lack of computerised technology. Interventions to decrease medication-related adverse events in the NICU should aim to increase staff awareness of medication safety issues and focus on medication administration processes.

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.

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

PubMed

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

2017-09-01

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

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.

Development and validation of Aviation Causal Contributors for Error Reporting Systems (ACCERS).

PubMed

Baker, David P; Krokos, Kelley J

2007-04-01

This investigation sought to develop a reliable and valid classification system for identifying and classifying the underlying causes of pilot errors reported under the Aviation Safety Action Program (ASAP). ASAP is a voluntary safety program that air carriers may establish to study pilot and crew performance on the line. In ASAP programs, similar to the Aviation Safety Reporting System, pilots self-report incidents by filing a short text description of the event. The identification of contributors to errors is critical if organizations are to improve human performance, yet it is difficult for analysts to extract this information from text narratives. A taxonomy was needed that could be used by pilots to classify the causes of errors. After completing a thorough literature review, pilot interviews and a card-sorting task were conducted in Studies 1 and 2 to develop the initial structure of the Aviation Causal Contributors for Event Reporting Systems (ACCERS) taxonomy. The reliability and utility of ACCERS was then tested in studies 3a and 3b by having pilots independently classify the primary and secondary causes of ASAP reports. The results provided initial evidence for the internal and external validity of ACCERS. Pilots were found to demonstrate adequate levels of agreement with respect to their category classifications. ACCERS appears to be a useful system for studying human error captured under pilot ASAP reports. Future work should focus on how ACCERS is organized and whether it can be used or modified to classify human error in ASAP programs for other aviation-related job categories such as dispatchers. Potential applications of this research include systems in which individuals self-report errors and that attempt to extract and classify the causes of those events.

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.

Report of the Odyssey FPGA Independent Assessment Team

NASA Technical Reports Server (NTRS)

Mayer, Donald C.; Katz, Richard B.; Osborn, Jon V.; Soden, Jerry M.; Barto, R.; Day, John H. (Technical Monitor)

2001-01-01

An independent assessment team (IAT) was formed and met on April 2, 2001, at Lockheed Martin in Denver, Colorado, to aid in understanding a technical issue for the Mars Odyssey spacecraft scheduled for launch on April 7, 2001. An RP1280A field-programmable gate array (FPGA) from a lot of parts common to the SIRTF, Odyssey, and Genesis missions had failed on a SIRTF printed circuit board. A second FPGA from an earlier Odyssey circuit board was also known to have failed and was also included in the analysis by the IAT. Observations indicated an abnormally high failure rate for flight RP1280A devices (the first flight lot produced using this flow) at Lockheed Martin and the causes of these failures were not determined. Standard failure analysis techniques were applied to these parts, however, additional diagnostic techniques unique for devices of this class were not used, and the parts were prematurely submitted to a destructive physical analysis, making a determination of the root cause of failure difficult. Any of several potential failure scenarios may have caused these failures, including electrostatic discharge, electrical overstress, manufacturing defects, board design errors, board manufacturing errors, FPGA design errors, or programmer errors. Several of these mechanisms would have relatively benign consequences for disposition of the parts currently installed on boards in the Odyssey spacecraft if established as the root cause of failure. However, other potential failure mechanisms could have more dire consequences. As there is no simple way to determine the likely failure mechanisms with reasonable confidence before Odyssey launch, it is not possible for the IAT to recommend a disposition for the other parts on boards in the Odyssey spacecraft based on sound engineering principles.

An automated microphysiological assay for toxicity evaluation.

PubMed

Eggert, S; Alexander, F A; Wiest, J

2015-08-01

Screening a newly developed drug, food additive or cosmetic ingredient for toxicity is a critical preliminary step before it can move forward in the development pipeline. Due to the sometimes dire consequences when a harmful agent is overlooked, toxicologists work under strict guidelines to effectively catalogue and classify new chemical agents. Conventional assays involve long experimental hours and many manual steps that increase the probability of user error; errors that can potentially manifest as inaccurate toxicology results. Automated assays can overcome many potential mistakes that arise due to human error. In the presented work, we created and validated a novel, automated platform for a microphysiological assay that can examine cellular attributes with sensors measuring changes in cellular metabolic rate, oxygen consumption, and vitality mediated by exposure to a potentially toxic agent. The system was validated with low buffer culture medium with varied conductivities that caused changes in the measured impedance on integrated impedance electrodes.

Using medication list--problem list mismatches as markers of potential error.

PubMed Central

Carpenter, James D.; Gorman, Paul N.

2002-01-01

The goal of this project was to specify and develop an algorithm that will check for drug and problem list mismatches in an electronic medical record (EMR). The algorithm is based on the premise that a patient's problem list and medication list should agree, and a mismatch may indicate medication error. Successful development of this algorithm could mean detection of some errors, such as medication orders entered into a wrong patient record, or drug therapy omissions, that are not otherwise detected via automated means. Additionally, mismatches may identify opportunities to improve problem list integrity. To assess the concept's feasibility, this study compared medications listed in a pharmacy information system with findings in an online nursing adult admission assessment, serving as a proxy for the problem list. Where drug and problem list mismatches were discovered, examination of the patient record confirmed the mismatch, and identified any potential causes. Evaluation of the algorithm in diabetes treatment indicates that it successfully detects both potential medication error and opportunities to improve problem list completeness. This algorithm, once fully developed and deployed, could prove a valuable way to improve the patient problem list, and could decrease the risk of medication error. PMID:12463796

Methods for the computation of detailed geoids and their accuracy

NASA Technical Reports Server (NTRS)

Rapp, R. H.; Rummel, R.

1975-01-01

Two methods for the computation of geoid undulations using potential coefficients and 1 deg x 1 deg terrestrial anomaly data are examined. It was found that both methods give the same final result but that one method allows a more simplified error analysis. Specific equations were considered for the effect of the mass of the atmosphere and a cap dependent zero-order undulation term was derived. Although a correction to a gravity anomaly for the effect of the atmosphere is only about -0.87 mgal, this correction causes a fairly large undulation correction that was not considered previously. The accuracy of a geoid undulation computed by these techniques was estimated considering anomaly data errors, potential coefficient errors, and truncation (only a finite set of potential coefficients being used) errors. It was found that an optimum cap size of 20 deg should be used. The geoid and its accuracy were computed in the Geos 3 calibration area using the GEM 6 potential coefficients and 1 deg x 1 deg terrestrial anomaly data. The accuracy of the computed geoid is on the order of plus or minus 2 m with respect to an unknown set of best earth parameter constants.

Evaluation of Baroreflex Effectiveness Index during Real and Simulated Microgravity: Relation to Orthostatic Intolerance

NASA Technical Reports Server (NTRS)

Moore, Rachel; Stenger, Michael; Platts, Steven; Lee, Stuart

2013-01-01

Bed Rest and Space Flight cause a significant decrease in BEI. BR causes similar changes to BEI as SF. BEI may not correlate with subjects experiencing presyncope, but error is high and n is low. Compression Garments have the potential to restore BEI after short duration BR, but do not prevent recovery.

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.

Inpatient medical errors involving glucose-lowering medications and their impact on patients: review of 2,598 incidents from a voluntary electronic error-reporting database.

PubMed

Amori, Renee E; Pittas, Anastassios G; Siegel, Richard D; Kumar, Sanjaya; Chen, Jack S; Karnam, Suneel; Golden, Sherita H; Salem, Deeb N

2008-01-01

To describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care. We conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care. The median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported <2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports). An e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm.

E-prescribing errors in community pharmacies: exploring consequences and contributing factors.

PubMed

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

2014-06-01

To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors. Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10. Pharmacy staff detected 75 e-prescription errors during the 45 h observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information. Study findings suggest that a wide range of e-prescribing errors is encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

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

The use of source memory to identify one's own episodic confusion errors.

PubMed

Smith, S M; Tindell, D R; Pierce, B H; Gilliland, T R; Gerkens, D R

2001-03-01

In 4 category cued recall experiments, participants falsely recalled nonlist common members, a semantic confusion error. Errors were more likely if critical nonlist words were presented on an incidental task, causing source memory failures called episodic confusion errors. Participants could better identify the source of falsely recalled words if they had deeply processed the words on the incidental task. For deep but not shallow processing, participants could reliably include or exclude incidentally shown category members in recall. The illusion that critical items actually appeared on categorized lists was diminished but not eradicated when participants identified episodic confusion errors post hoc among their own recalled responses; participants often believed that critical items had been on both the incidental task and the study list. Improved source monitoring can potentially mitigate episodic (but not semantic) confusion errors.

Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out?

PubMed

Suba, Eric J; Pfeifer, John D; Raab, Stephen S

2007-10-01

Patient identification errors in surgical pathology often involve switches of prostate or breast needle core biopsy specimens among patients. We assessed strategies for decreasing the occurrence of these uncommon and yet potentially catastrophic events. Root cause analyses were performed following 3 cases of patient identification error involving prostate needle core biopsy specimens. Patient identification errors in surgical pathology result from slips and lapses of automatic human action that may occur at numerous steps during pre-laboratory, laboratory and post-laboratory work flow processes. Patient identification errors among prostate needle biopsies may be difficult to entirely prevent through the optimization of work flow processes. A DNA time-out, whereby DNA polymorphic microsatellite analysis is used to confirm patient identification before radiation therapy or radical surgery, may eliminate patient identification errors among needle biopsies.

Inborn Errors of Fructose Metabolism. What Can We Learn from Them?

PubMed

Tran, Christel

2017-04-03

Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases.

Inborn Errors of Fructose Metabolism. What Can We Learn from Them?

PubMed Central

Tran, Christel

2017-01-01

Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases. PMID:28368361

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

Controlling Reflections from Mesh Refinement Interfaces in Numerical Relativity

NASA Technical Reports Server (NTRS)

Baker, John G.; Van Meter, James R.

2005-01-01

A leading approach to improving the accuracy on numerical relativity simulations of black hole systems is through fixed or adaptive mesh refinement techniques. We describe a generic numerical error which manifests as slowly converging, artificial reflections from refinement boundaries in a broad class of mesh-refinement implementations, potentially limiting the effectiveness of mesh- refinement techniques for some numerical relativity applications. We elucidate this numerical effect by presenting a model problem which exhibits the phenomenon, but which is simple enough that its numerical error can be understood analytically. Our analysis shows that the effect is caused by variations in finite differencing error generated across low and high resolution regions, and that its slow convergence is caused by the presence of dramatic speed differences among propagation modes typical of 3+1 relativity. Lastly, we resolve the problem, presenting a class of finite-differencing stencil modifications which eliminate this pathology in both our model problem and in numerical relativity examples.

Comparison of Procedures for Dual and Triple Closely Spaced Parallel Runways

NASA Technical Reports Server (NTRS)

Verma, Savita; Ballinger, Deborah; Subramanian Shobana; Kozon, Thomas

2012-01-01

A human-in-the-loop high fidelity flight simulation experiment was conducted, which investigated and compared breakout procedures for Very Closely Spaced Parallel Approaches (VCSPA) with two and three runways. To understand the feasibility, usability and human factors of two and three runway VCSPA, data were collected and analyzed on the dependent variables of breakout cross track error and pilot workload. Independent variables included number of runways, cause of breakout and location of breakout. Results indicated larger cross track error and higher workload using three runways as compared to 2-runway operations. Significant interaction effects involving breakout cause and breakout location were also observed. Across all conditions, cross track error values showed high levels of breakout trajectory accuracy and pilot workload remained manageable. Results suggest possible avenues of future adaptation for adopting these procedures (e.g., pilot training), while also showing potential promise of the concept.

Descriptive analysis of medication errors reported to the Egyptian national online reporting system during six months.

PubMed

Shehata, Zahraa Hassan Abdelrahman; Sabri, Nagwa Ali; Elmelegy, Ahmed Abdelsalam

2016-03-01

This study analyzes reports to the Egyptian medication error (ME) reporting system from June to December 2014. Fifty hospital pharmacists received training on ME reporting using the national reporting system. All received reports were reviewed and analyzed. The pieces of data analyzed were patient age, gender, clinical setting, stage, type, medication(s), outcome, cause(s), and recommendation(s). Over the course of 6 months, 12,000 valid reports were gathered and included in this analysis. The majority (66%) came from inpatient settings, while 23% came from intensive care units, and 11% came from outpatient departments. Prescribing errors were the most common type of MEs (54%), followed by monitoring (25%) and administration errors (16%). The most frequent error was incorrect dose (20%) followed by drug interactions, incorrect drug, and incorrect frequency. Most reports were potential (25%), prevented (11%), or harmless (51%) errors; only 13% of reported errors lead to patient harm. The top three medication classes involved in reported MEs were antibiotics, drugs acting on the central nervous system, and drugs acting on the cardiovascular system. Causes of MEs were mostly lack of knowledge, environmental factors, lack of drug information sources, and incomplete prescribing. Recommendations for addressing MEs were mainly staff training, local ME reporting, and improving work environment. There are common problems among different healthcare systems, so that sharing experiences on the national level is essential to enable learning from MEs. Internationally, there is a great need for standardizing ME terminology, to facilitate knowledge transfer. Underreporting, inaccurate reporting, and a lack of reporter diversity are some limitations of this study. Egypt now has a national database of MEs that allows researchers and decision makers to assess the problem, identify its root causes, and develop preventive strategies. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Identifying high-risk medication: a systematic literature review.

PubMed

Saedder, Eva A; Brock, Birgitte; Nielsen, Lars Peter; Bonnerup, Dorthe K; Lisby, Marianne

2014-06-01

A medication error (ME) is an error that causes damage or poses a threat of harm to a patient. Several studies have shown that only a minority of MEs actually causes harm, and this might explain why medication reviews at hospital admission reduce the number of MEs without showing an effect on length of hospital stay, readmissions, or death. The purpose of this study was to define drugs that actually cause serious MEs. We conducted a literature search of medication reviews and other preventive efforts. A systematic search in PubMed, Embase, Cochrane Reviews, Psycinfo, and SweMed+ was performed. Danish databases containing published patient complaints, patient compensation, and reported medication errors were also searched. Articles and case reports were included if they contained information of an ME causing a serious adverse reaction (AR) in a patient. Information concerning AR seriousness, causality, and preventability was required for inclusion. This systematic literature review revealed that 47 % of all serious MEs were caused by seven drugs or drug classes: methotrexate, warfarin, nonsteroidal anti-inflammatory drugs (NSAIDS), digoxin, opioids, acetylic salicylic acid, and beta-blockers; 30 drugs or drug classes caused 82 % of all serious MEs. The top ten drugs involved in fatal events accounted for 73 % of all drugs identified. Increasing focus on seven drugs/drug classes can potentially reduce hospitalizations, extended hospitalizations, disability, life-threatening conditions, and death by almost 50 %.

Software reliability experiments data analysis and investigation

NASA Technical Reports Server (NTRS)

Walker, J. Leslie; Caglayan, Alper K.

1991-01-01

The objectives are to investigate the fundamental reasons which cause independently developed software programs to fail dependently, and to examine fault tolerant software structures which maximize reliability gain in the presence of such dependent failure behavior. The authors used 20 redundant programs from a software reliability experiment to analyze the software errors causing coincident failures, to compare the reliability of N-version and recovery block structures composed of these programs, and to examine the impact of diversity on software reliability using subpopulations of these programs. The results indicate that both conceptually related and unrelated errors can cause coincident failures and that recovery block structures offer more reliability gain than N-version structures if acceptance checks that fail independently from the software components are available. The authors present a theory of general program checkers that have potential application for acceptance tests.

Aquatic habitat mapping with an acoustic doppler current profiler: Considerations for data quality

USGS Publications Warehouse

Gaeuman, David; Jacobson, Robert B.

2005-01-01

When mounted on a boat or other moving platform, acoustic Doppler current profilers (ADCPs) can be used to map a wide range of ecologically significant phenomena, including measures of fluid shear, turbulence, vorticity, and near-bed sediment transport. However, the instrument movement necessary for mapping applications can generate significant errors, many of which have not been inadequately described. This report focuses on the mechanisms by which moving-platform errors are generated, and quantifies their magnitudes under typical habitat-mapping conditions. The potential for velocity errors caused by mis-alignment of the instrument?s internal compass are widely recognized, but has not previously been quantified for moving instruments. Numerical analyses show that even relatively minor compass mis-alignments can produce significant velocity errors, depending on the ratio of absolute instrument velocity to the target velocity and on the relative directions of instrument and target motion. A maximum absolute instrument velocity of about 1 m/s is recommended for most mapping applications. Lower velocities are appropriate when making bed velocity measurements, an emerging application that makes use of ADCP bottom-tracking to measure the velocity of sediment particles at the bed. The mechanisms by which heterogeneities in the flow velocity field generate horizontal velocities errors are also quantified, and some basic limitations in the effectiveness of standard error-detection criteria for identifying these errors are described. Bed velocity measurements may be particularly vulnerable to errors caused by spatial variability in the sediment transport field.

The effect of grid transparency and finite collector size on determining ion temperature and density by the retarding potential analyzer

NASA Technical Reports Server (NTRS)

Troy, B. E., Jr.; Maier, E. J.

1973-01-01

The analysis of ion data from retarding potential analyzers (RPA's) is generally done under the planar approximation, which assumes that the grid transparency is constant with angle of incidence and that all ions reaching the plane of the collectors are collected. These approximations are not valid for situations in which the ion thermal velocity is comparable to the vehicle velocity, causing ions to enter the RPA with high average transverse velocity. To investigate these effects, the current-voltage curves for H+ at 4000 K were calculated, taking into account the finite collector size and the variation of grid transparency with angle. These curves are then analyzed under the planar approximation. The results show that only small errors in temperature and density are introduced for an RPA with typical dimensions; and that even when the density error is substantial for non-typical dimensions, the temperature error remains minimal.

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

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.

Using heuristic evaluations to assess the safety of health information systems.

PubMed

Carvalho, Christopher J; Borycki, Elizabeth M; Kushniruk, Andre W

2009-01-01

Health information systems (HISs) are typically seen as a mechanism for reducing medical errors. There is, however, evidence to prove that technology may actually be the cause of errors. As a result, it is crucial to fully test any system prior to its implementation. At present, evidence-based evaluation heuristics do not exist for assessing aspects of interface design that lead to medical errors. A three phase study was conducted to develop evidence-based heuristics for evaluating interfaces. Phase 1 consisted of a systematic review of the literature. In Phase 2 a comprehensive list of 33 evaluation heuristics was developed based on the review that could be used to test for potential technology induced errors. Phase 3 involved applying these healthcare specific heuristics to evaluate a HIS.

Alleviating the Common Confusion Caused by Polarity in Electrochemistry.

ERIC Educational Resources Information Center

Moran, P. J.; Gileadi, E.

1989-01-01

Discussed is some of the confusion encountered in electrochemistry due to misunderstandings of sign conventions and simple mathematical errors. Clarified are issues involving emf series, IUPAC sign conventions, calculation of cell potentials, reference electrodes, the polarity of electrodes in electrochemical devices, and overpotential. (CW)

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.

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

PubMed

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

2017-12-01

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

The GEnes in Myopia (GEM) study in understanding the aetiology of refractive errors.

PubMed

Baird, Paul N; Schäche, Maria; Dirani, Mohamed

2010-11-01

Refractive errors represent the leading cause of correctable vision impairment and blindness in the world with an estimated 2 billion people affected. Refractive error refers to a group of refractive conditions including hypermetropia, myopia, astigmatism and presbyopia but relatively little is known about their aetiology. In order to explore the potential role of genetic determinants in refractive error the "GEnes in Myopia (GEM) study" was established in 2004. The findings that have resulted from this study have not only provided greater insight into the role of genes and other factors involved in myopia but have also gone some way to uncovering the aetiology of other refractive errors. This review will describe some of the major findings of the GEM study and their relative contribution to the literature, illuminate where the deficiencies are in our understanding of the development of refractive errors and how we will advance this field in the future. Copyright © 2010 Elsevier Ltd. All rights reserved.

Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors.

PubMed

Kupas, Douglas F; Shayhorn, Meghan A; Green, Paul; Payton, Thomas F

2012-01-01

Medications are essential to emergency medical services (EMS) agencies when providing lifesaving care, but the EMS environment has challenges related to safe medication storage when compared with a hospital setting. We developed a structured process, based on common pharmacy practices, to review medications carried by EMS agencies to identify situations that may lead to medication error and to determine some best practices that may reduce potential errors and the risk of patient harm. To provide a descriptive account of EMS practices related to carrying and storing medications that have the potential for causing a medication administration error or patient harm. Using a structured process for inspection, an emergency medicine pharmacist and emergency physician(s) reviewed the medication carrying and storage practices of all nine advanced life support ambulance agencies within a five-county EMS region. Each medication carried and stored by the EMS agency was inspected for predetermined and spontaneously observed issues that could lead to medication error. These issues were documented and photographed. Two EMS medical directors reviewed each potential error for the risk of producing patient harm and assigned each to a category of high, moderate, or low risk. Because issues of temperature on EMS medications have been addressed elsewhere, this study concentrated on potential for EMS medication administration errors exclusive of storage temperatures. When reviewing medications carried by the nine EMS agencies, 38 medication safety issues were identified (range 1 to 8 per EMS agency). Of these, 16 were considered to be high risk, 14 moderate risk, and eight low risk for patient harm. Examples of potential issues included carrying expired medications, container-labeling issues, different medications stored in look-alike vials or prefilled syringes in the same compartment, and carrying crystalloid solutions next to solutions premixed with a medication. When reviewing medications stored at the EMS agency stations, eight safety issues were identified (range from 0 to 4 per station), including five moderate-risk and three low-risk issues. No agency had any high-risk medication issues related to storage of medication stock in the station. We observed potential medication safety issues related to how medications are carried and stored at all nine EMS agencies in a five-county region. Understanding these issues may assist EMS agencies in reducing the potential for a medication error and risk of patient harm. More research is needed to determine whether following these suggested best practices for carrying medications on EMS vehicles actually reduces errors in medication administration by EMS providers or decreases patient harm.

A theory of human error

NASA Technical Reports Server (NTRS)

Mcruer, D. T.; Clement, W. F.; Allen, R. W.

1981-01-01

Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

[Errors in medicine. Causes, impact and improvement measures to improve patient safety].

PubMed

Waeschle, R M; Bauer, M; Schmidt, C E

2015-09-01

The guarantee of quality of care and patient safety is of major importance in hospitals even though increased economic pressure and work intensification are ubiquitously present. Nevertheless, adverse events still occur in 3-4 % of hospital stays and of these 25-50 % are estimated to be avoidable. The identification of possible causes of error and the development of measures for the prevention of medical errors are essential for patient safety. The implementation and continuous development of a constructive culture of error tolerance are fundamental.The origins of errors can be differentiated into systemic latent and individual active causes and components of both categories are typically involved when an error occurs. Systemic causes are, for example out of date structural environments, lack of clinical standards and low personnel density. These causes arise far away from the patient, e.g. management decisions and can remain unrecognized for a long time. Individual causes involve, e.g. confirmation bias, error of fixation and prospective memory failure. These causes have a direct impact on patient care and can result in immediate injury to patients. Stress, unclear information, complex systems and a lack of professional experience can promote individual causes. Awareness of possible causes of error is a fundamental precondition to establishing appropriate countermeasures.Error prevention should include actions directly affecting the causes of error and includes checklists and standard operating procedures (SOP) to avoid fixation and prospective memory failure and team resource management to improve communication and the generation of collective mental models. Critical incident reporting systems (CIRS) provide the opportunity to learn from previous incidents without resulting in injury to patients. Information technology (IT) support systems, such as the computerized physician order entry system, assist in the prevention of medication errors by providing information on dosage, pharmacological interactions, side effects and contraindications of medications.The major challenges for quality and risk management, for the heads of departments and the executive board is the implementation and support of the described actions and a sustained guidance of the staff involved in the modification management process. The global trigger tool is suitable for improving transparency and objectifying the frequency of medical errors.

Sustained Attention is Associated with Error Processing Impairment: Evidence from Mental Fatigue Study in Four-Choice Reaction Time Task

PubMed Central

Xiao, Yi; Ma, Feng; Lv, Yixuan; Cai, Gui; Teng, Peng; Xu, FengGang; Chen, Shanguang

2015-01-01

Attention is important in error processing. Few studies have examined the link between sustained attention and error processing. In this study, we examined how error-related negativity (ERN) of a four-choice reaction time task was reduced in the mental fatigue condition and investigated the role of sustained attention in error processing. Forty-one recruited participants were divided into two groups. In the fatigue experiment group, 20 subjects performed a fatigue experiment and an additional continuous psychomotor vigilance test (PVT) for 1 h. In the normal experiment group, 21 subjects only performed the normal experimental procedures without the PVT test. Fatigue and sustained attention states were assessed with a questionnaire. Event-related potential results showed that ERN (p < 0.005) and peak (p < 0.05) mean amplitudes decreased in the fatigue experiment. ERN amplitudes were significantly associated with the attention and fatigue states in electrodes Fz, FC1, Cz, and FC2. These findings indicated that sustained attention was related to error processing and that decreased attention is likely the cause of error processing impairment. PMID:25756780

Are Charitable Giving and Religious Attendance Complements or Substitutes? The Role of Measurement Error

ERIC Educational Resources Information Center

Kim, Matthew

2013-01-01

Government policies sometimes cause unintended consequences for other potentially desirable behaviors. One such policy is the charitable tax deduction, which encourages charitable giving by allowing individuals to deduct giving from taxable income. Whether charitable giving and other desirable behaviors are complements or substitutes affect the…

Irregular analytical errors in diagnostic testing - a novel concept.

PubMed

Vogeser, Michael; Seger, Christoph

2018-02-23

In laboratory medicine, routine periodic analyses for internal and external quality control measurements interpreted by statistical methods are mandatory for batch clearance. Data analysis of these process-oriented measurements allows for insight into random analytical variation and systematic calibration bias over time. However, in such a setting, any individual sample is not under individual quality control. The quality control measurements act only at the batch level. Quantitative or qualitative data derived for many effects and interferences associated with an individual diagnostic sample can compromise any analyte. It is obvious that a process for a quality-control-sample-based approach of quality assurance is not sensitive to such errors. To address the potential causes and nature of such analytical interference in individual samples more systematically, we suggest the introduction of a new term called the irregular (individual) analytical error. Practically, this term can be applied in any analytical assay that is traceable to a reference measurement system. For an individual sample an irregular analytical error is defined as an inaccuracy (which is the deviation from a reference measurement procedure result) of a test result that is so high it cannot be explained by measurement uncertainty of the utilized routine assay operating within the accepted limitations of the associated process quality control measurements. The deviation can be defined as the linear combination of the process measurement uncertainty and the method bias for the reference measurement system. Such errors should be coined irregular analytical errors of the individual sample. The measurement result is compromised either by an irregular effect associated with the individual composition (matrix) of the sample or an individual single sample associated processing error in the analytical process. Currently, the availability of reference measurement procedures is still highly limited, but LC-isotope-dilution mass spectrometry methods are increasingly used for pre-market validation of routine diagnostic assays (these tests also involve substantial sets of clinical validation samples). Based on this definition/terminology, we list recognized causes of irregular analytical error as a risk catalog for clinical chemistry in this article. These issues include reproducible individual analytical errors (e.g. caused by anti-reagent antibodies) and non-reproducible, sporadic errors (e.g. errors due to incorrect pipetting volume due to air bubbles in a sample), which can both lead to inaccurate results and risks for patients.

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

Influence of non-ideal performance of lasers on displacement precision in single-grating heterodyne interferometry

NASA Astrophysics Data System (ADS)

Wang, Guochao; Xie, Xuedong; Yan, Shuhua

2010-10-01

Principle of the dual-wavelength single grating nanometer displacement measuring system, with a long range, high precision, and good stability, is presented. As a result of the nano-level high-precision displacement measurement, the error caused by a variety of adverse factors must be taken into account. In this paper, errors, due to the non-ideal performance of the dual-frequency laser, including linear error caused by wavelength instability and non-linear error caused by elliptic polarization of the laser, are mainly discussed and analyzed. On the basis of theoretical modeling, the corresponding error formulas are derived as well. Through simulation, the limit value of linear error caused by wavelength instability is 2nm, and on the assumption that 0.85 x T = , 1 Ty = of the polarizing beam splitter(PBS), the limit values of nonlinear-error caused by elliptic polarization are 1.49nm, 2.99nm, 4.49nm while the non-orthogonal angle is selected correspondingly at 1°, 2°, 3° respectively. The law of the error change is analyzed based on different values of Tx and Ty .

Tailoring a Human Reliability Analysis to Your Industry Needs

NASA Technical Reports Server (NTRS)

DeMott, D. L.

2016-01-01

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.

Underestimation of Low-Dose Radiation in Treatment Planning of Intensity-Modulated Radiotherapy

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

Jang, Si Young; Liu, H. Helen; Mohan, Radhe

2008-08-01

Purpose: To investigate potential dose calculation errors in the low-dose regions and identify causes of such errors for intensity-modulated radiotherapy (IMRT). Methods and Materials: The IMRT treatment plans of 23 patients with lung cancer and mesothelioma were reviewed. Of these patients, 15 had severe pulmonary complications after radiotherapy. Two commercial treatment-planning systems (TPSs) and a Monte Carlo system were used to calculate and compare dose distributions and dose-volume parameters of the target volumes and critical structures. The effect of tissue heterogeneity, multileaf collimator (MLC) modeling, beam modeling, and other factors that could contribute to the differences in IMRT dose calculationsmore » were analyzed. Results: In the commercial TPS-generated IMRT plans, dose calculation errors primarily occurred in the low-dose regions of IMRT plans (<50% of the radiation dose prescribed for the tumor). Although errors in the dose-volume histograms of the normal lung were small (<5%) above 10 Gy, underestimation of dose <10 Gy was found to be up to 25% in patients with mesothelioma or large target volumes. These errors were found to be caused by inadequate modeling of MLC transmission and leaf scatter in commercial TPSs. The degree of low-dose errors depends on the target volumes and the degree of intensity modulation. Conclusions: Secondary radiation from MLCs contributes a significant portion of low dose in IMRT plans. Dose underestimation could occur in conventional IMRT dose calculations if such low-dose radiation is not properly accounted for.« less

Crystal Genetics, Inc.

PubMed

Kermani, Bahram G

2016-07-01

Crystal Genetics, Inc. is an early-stage genetic test company, focused on achieving the highest possible clinical-grade accuracy and comprehensiveness for detecting germline (e.g., in hereditary cancer) and somatic (e.g., in early cancer detection) mutations. Crystal's mission is to significantly improve the health status of the population, by providing high accuracy, comprehensive, flexible and affordable genetic tests, primarily in cancer. Crystal's philosophy is that when it comes to detecting mutations that are strongly correlated with life-threatening diseases, the detection accuracy of every single mutation counts: a single false-positive error could cause severe anxiety for the patient. And, more importantly, a single false-negative error could potentially cost the patient's life. Crystal's objective is to eliminate both of these error types.

Implementing technology to improve medication safety in healthcare facilities: a literature review.

PubMed

Hidle, Unn

Medication errors remain one of the most common causes of patient injuries in the United States, with detrimental outcomes including adverse reactions and even death. By developing a better understanding of why and how medication errors occur, preventative measures may be implemented including technological advances. In this literature review, potential methods of reducing medication errors were explored. Furthermore, technology tools available for medication orders and administration are described, including advantages and disadvantages of each system. It was found that technology can be an excellent aid in improving safety of medication administration. However, computer technology cannot replace human intellect and intuition. Nurses should be involved when implementing any new computerized system in order to obtain the most appropriate and user-friendly structure.

Hospital-based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient transfusion safety.

PubMed

Maskens, Carolyn; Downie, Helen; Wendt, Alison; Lima, Ana; Merkley, Lisa; Lin, Yulia; Callum, Jeannie

2014-01-01

This report provides a comprehensive analysis of transfusion errors occurring at a large teaching hospital and aims to determine key errors that are threatening transfusion safety, despite implementation of safety measures. Errors were prospectively identified from 2005 to 2010. Error data were coded on a secure online database called the Transfusion Error Surveillance System. Errors were defined as any deviation from established standard operating procedures. Errors were identified by clinical and laboratory staff. Denominator data for volume of activity were used to calculate rates. A total of 15,134 errors were reported with a median number of 215 errors per month (range, 85-334). Overall, 9083 (60%) errors occurred on the transfusion service and 6051 (40%) on the clinical services. In total, 23 errors resulted in patient harm: 21 of these errors occurred on the clinical services and two in the transfusion service. Of the 23 harm events, 21 involved inappropriate use of blood. Errors with no harm were 657 times more common than events that caused harm. The most common high-severity clinical errors were sample labeling (37.5%) and inappropriate ordering of blood (28.8%). The most common high-severity error in the transfusion service was sample accepted despite not meeting acceptance criteria (18.3%). The cost of product and component loss due to errors was $593,337. Errors occurred at every point in the transfusion process, with the greatest potential risk of patient harm resulting from inappropriate ordering of blood products and errors in sample labeling. © 2013 American Association of Blood Banks (CME).

Minimizing Artifacts and Biases in Chamber-Based Measurements of Soil Respiration

NASA Astrophysics Data System (ADS)

Davidson, E. A.; Savage, K.

2001-05-01

Soil respiration is one of the largest and most important fluxes of carbon in terrestrial ecosystems. The objectives of this paper are to review concerns about uncertainties of chamber-based measurements of CO2 emissions from soils, to evaluate the direction and magnitude of these potential errors, and to explain procedures that minimize these errors and biases. Disturbance of diffusion gradients cause underestimate of fluxes by less than 15% in most cases, and can be partially corrected for with curve fitting and/or can be minimized by using brief measurement periods. Under-pressurization or over-pressurization of the chamber caused by flow restrictions in air circulating designs can cause large errors, but can also be avoided with properly sized chamber vents and unrestricted flows. Somewhat larger pressure differentials are observed under windy conditions, and the accuracy of measurements made under such conditions needs more research. Spatial and temporal heterogeneity can be addressed with appropriate chamber sizes and numbers and frequency of sampling. For example, means of 8 randomly chosen flux measurements from a population of 36 measurements made with 300 cm2 chambers in tropical forests and pastures were within 25% of the full population mean 98% of the time and were within 10% of the full population mean 70% of the time. Comparisons of chamber-based measurements with tower-based measurements of total ecosystem respiration require analysis of the scale of variation within the purported tower footprint. In a forest at Howland, Maine, the differences in soil respiration rates among very poorly drained and well drained soils were large, but they mostly were fortuitously cancelled when evaluated for purported tower footprints of 600-2100 m length. While all of these potential sources of measurement error and sampling biases must be carefully considered, properly designed and deployed chambers provide a reliable means of accurately measuring soil respiration in terrestrial ecosystems.

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

Causes and consequences of timing errors associated with global positioning system collar accelerometer activity monitors

Treesearch

Adam J. Gaylord; Dana M. Sanchez

2014-01-01

Direct behavioral observations of multiple free-ranging animals over long periods of time and large geographic areas is prohibitively difficult. However, recent improvements in technology, such as Global Positioning System (GPS) collars equipped with motion-sensitive activity monitors, create the potential to remotely monitor animal behavior. Accelerometer-equipped...

Analysis of and Feedback on Phonetic Features in Pronunciation Training with a Virtual Teacher

ERIC Educational Resources Information Center

Engwall, Olov

2012-01-01

Pronunciation errors may be caused by several different deviations from the target, such as voicing, intonation, insertions or deletions of segments, or that the articulators are placed incorrectly. Computer-animated pronunciation teachers could potentially provide important assistance on correcting all these types of deviations, but they have an…

Technical Basis for Evaluating Software-Related Common-Cause Failures

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

Muhlheim, Michael David; Wood, Richard

2016-04-01

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

Benchmarking NLDAS-2 Soil Moisture and Evapotranspiration to Separate Uncertainty Contributions

NASA Technical Reports Server (NTRS)

Nearing, Grey S.; Mocko, David M.; Peters-Lidard, Christa D.; Kumar, Sujay V.; Xia, Youlong

2016-01-01

Model benchmarking allows us to separate uncertainty in model predictions caused 1 by model inputs from uncertainty due to model structural error. We extend this method with a large-sample approach (using data from multiple field sites) to measure prediction uncertainty caused by errors in (i) forcing data, (ii) model parameters, and (iii) model structure, and use it to compare the efficiency of soil moisture state and evapotranspiration flux predictions made by the four land surface models in the North American Land Data Assimilation System Phase 2 (NLDAS-2). Parameters dominated uncertainty in soil moisture estimates and forcing data dominated uncertainty in evapotranspiration estimates; however, the models themselves used only a fraction of the information available to them. This means that there is significant potential to improve all three components of the NLDAS-2 system. In particular, continued work toward refining the parameter maps and look-up tables, the forcing data measurement and processing, and also the land surface models themselves, has potential to result in improved estimates of surface mass and energy balances.

Benchmarking NLDAS-2 Soil Moisture and Evapotranspiration to Separate Uncertainty Contributions

PubMed Central

Nearing, Grey S.; Mocko, David M.; Peters-Lidard, Christa D.; Kumar, Sujay V.; Xia, Youlong

2018-01-01

Model benchmarking allows us to separate uncertainty in model predictions caused by model inputs from uncertainty due to model structural error. We extend this method with a “large-sample” approach (using data from multiple field sites) to measure prediction uncertainty caused by errors in (i) forcing data, (ii) model parameters, and (iii) model structure, and use it to compare the efficiency of soil moisture state and evapotranspiration flux predictions made by the four land surface models in the North American Land Data Assimilation System Phase 2 (NLDAS-2). Parameters dominated uncertainty in soil moisture estimates and forcing data dominated uncertainty in evapotranspiration estimates; however, the models themselves used only a fraction of the information available to them. This means that there is significant potential to improve all three components of the NLDAS-2 system. In particular, continued work toward refining the parameter maps and look-up tables, the forcing data measurement and processing, and also the land surface models themselves, has potential to result in improved estimates of surface mass and energy balances. PMID:29697706

Benchmarking NLDAS-2 Soil Moisture and Evapotranspiration to Separate Uncertainty Contributions.

PubMed

Nearing, Grey S; Mocko, David M; Peters-Lidard, Christa D; Kumar, Sujay V; Xia, Youlong

2016-03-01

Model benchmarking allows us to separate uncertainty in model predictions caused by model inputs from uncertainty due to model structural error. We extend this method with a "large-sample" approach (using data from multiple field sites) to measure prediction uncertainty caused by errors in (i) forcing data, (ii) model parameters, and (iii) model structure, and use it to compare the efficiency of soil moisture state and evapotranspiration flux predictions made by the four land surface models in the North American Land Data Assimilation System Phase 2 (NLDAS-2). Parameters dominated uncertainty in soil moisture estimates and forcing data dominated uncertainty in evapotranspiration estimates; however, the models themselves used only a fraction of the information available to them. This means that there is significant potential to improve all three components of the NLDAS-2 system. In particular, continued work toward refining the parameter maps and look-up tables, the forcing data measurement and processing, and also the land surface models themselves, has potential to result in improved estimates of surface mass and energy balances.

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.

42 CFR 431.992 - Corrective action plan.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CMS, designed to reduce improper payments in each program based on its analysis of the error causes in... State must take the following actions: (1) Data analysis. States must conduct data analysis such as reviewing clusters of errors, general error causes, characteristics, and frequency of errors that are...

42 CFR 431.992 - Corrective action plan.

Code of Federal Regulations, 2011 CFR

2011-10-01

... CMS, designed to reduce improper payments in each program based on its analysis of the error causes in... State must take the following actions: (1) Data analysis. States must conduct data analysis such as reviewing clusters of errors, general error causes, characteristics, and frequency of errors that are...

An assessment of the cultivated cropland class of NLCD 2006 using a multi-source and multi-criteria approach

USGS Publications Warehouse

Danielson, Patrick; Yang, Limin; Jin, Suming; Homer, Collin G.; Napton, Darrell

2016-01-01

We developed a method that analyzes the quality of the cultivated cropland class mapped in the USA National Land Cover Database (NLCD) 2006. The method integrates multiple geospatial datasets and a Multi Index Integrated Change Analysis (MIICA) change detection method that captures spectral changes to identify the spatial distribution and magnitude of potential commission and omission errors for the cultivated cropland class in NLCD 2006. The majority of the commission and omission errors in NLCD 2006 are in areas where cultivated cropland is not the most dominant land cover type. The errors are primarily attributed to the less accurate training dataset derived from the National Agricultural Statistics Service Cropland Data Layer dataset. In contrast, error rates are low in areas where cultivated cropland is the dominant land cover. Agreement between model-identified commission errors and independently interpreted reference data was high (79%). Agreement was low (40%) for omission error comparison. The majority of the commission errors in the NLCD 2006 cultivated crops were confused with low-intensity developed classes, while the majority of omission errors were from herbaceous and shrub classes. Some errors were caused by inaccurate land cover change from misclassification in NLCD 2001 and the subsequent land cover post-classification process.

Radial orbit error reduction and sea surface topography determination using satellite altimetry

NASA Technical Reports Server (NTRS)

Engelis, Theodossios

1987-01-01

A method is presented in satellite altimetry that attempts to simultaneously determine the geoid and sea surface topography with minimum wavelengths of about 500 km and to reduce the radial orbit error caused by geopotential errors. The modeling of the radial orbit error is made using the linearized Lagrangian perturbation theory. Secular and second order effects are also included. After a rather extensive validation of the linearized equations, alternative expressions of the radial orbit error are derived. Numerical estimates for the radial orbit error and geoid undulation error are computed using the differences of two geopotential models as potential coefficient errors, for a SEASAT orbit. To provide statistical estimates of the radial distances and the geoid, a covariance propagation is made based on the full geopotential covariance. Accuracy estimates for the SEASAT orbits are given which agree quite well with already published results. Observation equations are develped using sea surface heights and crossover discrepancies as observables. A minimum variance solution with prior information provides estimates of parameters representing the sea surface topography and corrections to the gravity field that is used for the orbit generation. The simulation results show that the method can be used to effectively reduce the radial orbit error and recover the sea surface topography.

Improving the safety of vaccine delivery.

PubMed

Evans, Huw P; Cooper, Alison; Williams, Huw; Carson-Stevens, Andrew

2016-05-03

Vaccines save millions of lives per annum as an integral part of community primary care provision worldwide. Adverse events due to the vaccine delivery process outnumber those arising from the pharmacological properties of the vaccines themselves. Whilst one in three patients receiving a vaccine will encounter some form of error, little is known about their underlying causes and how to mitigate them in practice. Patient safety incident reporting systems and adverse drug event surveillance offer a rich opportunity for understanding the underlying causes of those errors. Reducing harm relies on the identification and implementation of changes to improve vaccine safety at multiple levels: from patient interventions through to organizational actions at local, national and international levels. Here we highlight the potential for maximizing learning from patient safety incident reports to improve the quality and safety of vaccine delivery.

Unconventional Rotor Power Response to Yaw Error Variations

DOE PAGES

Schreck, S. J.; Schepers, J. G.

2014-12-16

Continued inquiry into rotor and blade aerodynamics remains crucial for achieving accurate, reliable prediction of wind turbine power performance under yawed conditions. To exploit key advantages conferred by controlled inflow conditions, we used EU-JOULE DATA Project and UAE Phase VI experimental data to characterize rotor power production under yawed conditions. Anomalies in rotor power variation with yaw error were observed, and the underlying fluid dynamic interactions were isolated. Unlike currently recognized influences caused by angled inflow and skewed wake, which may be considered potential flow interactions, these anomalies were linked to pronounced viscous and unsteady effects.

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

PubMed

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

2015-01-01

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

Learning from patients: Identifying design features of medicines that cause medication use problems.

PubMed

Notenboom, Kim; Leufkens, Hubert Gm; Vromans, Herman; Bouvy, Marcel L

2017-01-30

Usability is a key factor in ensuring safe and efficacious use of medicines. However, several studies showed that people experience a variety of problems using their medicines. The purpose of this study was to identify design features of oral medicines that cause use problems among older patients in daily practice. A qualitative study with semi-structured interviews on the experiences of older people with the use of their medicines was performed (n=59). Information on practical problems, strategies to overcome these problems and the medicines' design features that caused these problems were collected. The practical problems and management strategies were categorised into 'use difficulties' and 'use errors'. A total of 158 use problems were identified, of which 45 were categorized as use difficulties and 113 as use error. Design features that contributed the most to the occurrence of use difficulties were the dimensions and surface texture of the dosage form (29.6% and 18.5%, respectively). Design features that contributed the most to the occurrence of use errors were the push-through force of blisters (22.1%) and tamper evident packaging (12.1%). These findings will help developers of medicinal products to proactively address potential usability issues with their medicines. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.

On the Effects of a Spacecraft Subcarrier Unbalanced Modulator

NASA Technical Reports Server (NTRS)

Nguyen, Tien Manh

1993-01-01

This paper presents mathematical models with associated analysis of the deleterious effects which a spacecraft's subcarrier unbalanced modulator has on the performance of a phase-modulated residual carrier communications link. The undesired spectral components produced by the phase and amplitude imbalances in the subcarrier modulator can cause (1) potential interference to the carrier tracking and (2) degradation in the telemetry bit signal-to-noise ratio (SNR). A suitable model for the unbalanced modulator is developed and the threshold levels of undesired components that fall into the carrier tracking loop are determined. The distribution of the carrier phase error caused by the additive White Gaussian noise (AWGN) and undesired component at the residual RF carrier is derived for the limiting cases. Further, this paper analyses the telemetry bit signal-to-noise ratio degradations due to undesirable spectral components as well as the carrier tracking phase error induced by phase and amplitude imbalances. Numerical results which indicate the sensitivity of the carrier tracking loop and the telemetry symbol-error rate (SER) to various parameters of the models are also provided as a tool in the design of the subcarrier balanced modulator.

Sepsis in Poland: Why Do We Die?

PubMed Central

Rorat, Marta; Jurek, Tomasz

2015-01-01

Objective To investigate the adverse events and potential risk factors in patients who develop sepsis. Subjects and Methods Fifty-five medico-legal opinion forms relating to sepsis cases issued by the Department of Forensic Medicine, Wroclaw, Poland, between 2004 and 2013 were analyzed for medical errors and risk factors for adverse events. Results The most common causes of medical errors were a lack of knowledge in recognition, diagnosis and therapy as well as ignorance of risk. The common risk factors for adverse events were deferral of a diagnostic or therapeutic decision, high-level anxiety of patients or their families about the patient's health and actively seeking for help. The most significant risk factors were communication errors, not enough medical staff, stereotype-based thinking about diseases and providing easy explanations for serious symptoms. Conclusion The most common cause of adverse events related to sepsis in the Polish health-care system was a lack of knowledge about the symptoms, diagnosis and treatment as well as the ignoring of danger. A possible means of improving safety might be through spreading knowledge and creating medical management algorithms for all health-care workers, especially physicians. PMID:25501966

Field guide to malformations of frogs and toads: with radiographic interpretations

USGS Publications Warehouse

Meteyer, Carol U.

2000-01-01

In 1995, students found numerous malformed frogs on a field trip to a Minnesota pond. Since that time, reports of malformed frogs have increased dramatically. Malformed frogs have now been reported in 44 states in 38 species of frogs, and 19 species of toads. Estimates as high as 60% of the newly metamorphosed frog populations have had malformations at some ponds (NARCAM, ’99). The wide geographic distribution of malformed frogs and the variety of malformations are a concern to resource managers, research scientists and public health officials. The potential for malformations to serve as a signal of ecosystem disruption, and the affect this potential disruption might have on other organisms that share those ecosystems, has not been resolved. Malformations represent an error that occurred early in development. The event that caused the developmental error is temporally distant from the malformation we see in the fully developed animal. Knowledge of normal developmental principles is necessary to design thoughtful investigations that will define the events involved in abnormal development in wild frog populations.Development begins at the time an egg is fertilized and progresses by chemical communication between cells and cell layers. This communication is programmed through gene expression. Malformations represent primary errors in development, errors in chemical communication or translation of genetic information. Deformations arise later in development and usually result from the influence of mechanical factors (such as amputation) that alter shape or anatomy of a structure that has developed normally. The occurrence and the type of malformations are influenced by the type of error or insult as well as the timing of the error (the developmental stage at which the error occurred). The appearance of the malformation can therefore provide clues that suggest when the error may have occurred. If the malformation is an incomplete organ, such as an incomplete limb, the factor or insult acted during a susceptible period prior to organ completion. Although defining the anatomy of the malformed metamorphosed frog can give us an idea of the approximate window during which the developmental insult was initiated, and might even suggest the type of insult that may have occurred, the morphology of the malformation does not define the cause. To define causes and mechanisms of frog malformations we need to use well designed investigations that are different from traditional tests used in acute toxicity or disease pathogenicity studies. When investigating malformations in metamorphosed frogs, we are looking at the affect of exposure to an agent that occurred early in tadpole development. Therefore investigations to determine causes of malformations need to look at agents that are present in the tadpoles or their environments at these early developmental times. Laboratory experiments need to expose embryos and tadpoles to suspect agents at appropriate developmental stages and look at acute results, such as toxicity and death, as well as following the developmental process to completion to determine the impact of the agent on the developing tadpole and the fully developed frog. This means holding animals past metamorphic climax to assure that the anatomy and physiology of the adult have developed normally.As we look at field collections of abnormal frogs, we need to keep in mind that these collections reflect survivors only. We are looking at malformations that were not fatal to tadpoles. We cannot assume that because we do not collect other malformations, they did not exist. More work needs to be done on the developing tadpole, in the field and in the laboratory, to better elucidate the range, frequency, character and causes of anuran malformations.

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

Corrigendum to "Sinusoidal potential cycling operation of a direct ethanol fuel cell to improving carbon dioxide yields" [J. Power Sources 268 (5 December 2014) 439-442

NASA Astrophysics Data System (ADS)

Majidi, Pasha; Pickup, Peter G.

2016-09-01

The authors regret that Equation (5) is incorrect and has resulted in errors in Fig. 4 and the efficiencies stated on p. 442. The corrected equation, figure and text are presented below. In addition, the title should be 'Sinusoidal potential cycling operation of a direct ethanol fuel cell to improve carbon dioxide yields', and the reversible cell potential quoted on p. 441 should be 1.14 V. The authors would like to apologise for any inconvenience caused.

Guidelines for the assessment and acceptance of potential brain-dead organ donors

PubMed Central

Westphal, Glauco Adrieno; Garcia, Valter Duro; de Souza, Rafael Lisboa; Franke, Cristiano Augusto; Vieira, Kalinca Daberkow; Birckholz, Viviane Renata Zaclikevis; Machado, Miriam Cristine; de Almeida, Eliana Régia Barbosa; Machado, Fernando Osni; Sardinha, Luiz Antônio da Costa; Wanzuita, Raquel; Silvado, Carlos Eduardo Soares; Costa, Gerson; Braatz, Vera; Caldeira Filho, Milton; Furtado, Rodrigo; Tannous, Luana Alves; de Albuquerque, André Gustavo Neves; Abdala, Edson; Gonçalves, Anderson Ricardo Roman; Pacheco-Moreira, Lúcio Filgueiras; Dias, Fernando Suparregui; Fernandes, Rogério; Giovanni, Frederico Di; de Carvalho, Frederico Bruzzi; Fiorelli, Alfredo; Teixeira, Cassiano; Feijó, Cristiano; Camargo, Spencer Marcantonio; de Oliveira, Neymar Elias; David, André Ibrahim; Prinz, Rafael Augusto Dantas; Herranz, Laura Brasil; de Andrade, Joel

2016-01-01

Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors. PMID:27737418

Reduction of construction wastes by improving construction contract management: a multinational evaluation.

PubMed

Mendis, Daylath; Hewage, Kasun N; Wrzesniewski, Joanna

2013-10-01

The Canadian construction industry generates 30% of the total municipal solid waste deposited in landfills. Ample evidence can be found in the published literature about rework and waste generation due to ambiguity and errors in contract documents. Also, the literature quotes that disclaimer clauses in contract documents are included in the contractual agreements to prevent contractor claims, which often cause rework. Our professional practice has also noted that there are several disclaimer clauses in standard contract documents which have the potential to cause rework (and associated waste). This article illustrates a comparative study of standard contractual documents and their potential to create rework (and associated waste) in different regions of the world. The objectives of this study are (1) to analyse standard contractual documents in Canada, the USA and Australia in terms of their potential to generate rework and waste, and (2) to propose changes/amendments to the existing standard contract documents to minimise/avoid rework. In terms of construction waste management, all the reviewed standard contract documents have deficiencies. The parties that produce the contract documents include exculpatory clauses to avoid the other party's claims. This approach tends to result in rework and construction waste. The contractual agreements/contract documents should be free from errors, deficiencies, ambiguity and unfair risk transfers to minimise/avoid potential to generate rework and waste.

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

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

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

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

A theory of human error

NASA Technical Reports Server (NTRS)

Mcruer, D. T.; Clement, W. F.; Allen, R. W.

1980-01-01

Human error, a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents is investigated. Correction of the sources of human error requires that one attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations is presented. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

Human Error as an Emergent Property of Action Selection and Task Place-Holding.

PubMed

Tamborello, Franklin P; Trafton, J Gregory

2017-05-01

A computational process model could explain how the dynamic interaction of human cognitive mechanisms produces each of multiple error types. With increasing capability and complexity of technological systems, the potential severity of consequences of human error is magnified. Interruption greatly increases people's error rates, as does the presence of other information to maintain in an active state. The model executed as a software-instantiated Monte Carlo simulation. It drew on theoretical constructs such as associative spreading activation for prospective memory, explicit rehearsal strategies as a deliberate cognitive operation to aid retrospective memory, and decay. The model replicated the 30% effect of interruptions on postcompletion error in Ratwani and Trafton's Stock Trader task, the 45% interaction effect on postcompletion error of working memory capacity and working memory load from Byrne and Bovair's Phaser Task, as well as the 5% perseveration and 3% omission effects of interruption from the UNRAVEL Task. Error classes including perseveration, omission, and postcompletion error fall naturally out of the theory. The model explains post-interruption error in terms of task state representation and priming for recall of subsequent steps. Its performance suggests that task environments providing more cues to current task state will mitigate error caused by interruption. For example, interfaces could provide labeled progress indicators or facilities for operators to quickly write notes about their task states when interrupted.

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, COL9A2, ERBB3, FBN1, GJA1, GNPTG, IFIH1, KIF11, LTBP2, OCA2, POLR3B, POMT1, PTPN11, TFAP2A, ZNF469). Conclusions Common genetic variants within or nearby genes that cause syndromic myopia are enriched for variants that cause nonsyndromic, common myopia. Analysis of syndromic forms of refractive errors can provide new insights into the etiology of myopia and additional potential targets for therapeutic interventions. PMID:29346494

A Case Study on Improving Intensive Care Unit (ICU) Services Reliability: By Using Process Failure Mode and Effects Analysis (PFMEA)

PubMed Central

Yousefinezhadi, Taraneh; Jannesar Nobari, Farnaz Attar; Goodari, Faranak Behzadi; Arab, Mohammad

2016-01-01

Introduction: In any complex human system, human error is inevitable and shows that can’t be eliminated by blaming wrong doers. So with the aim of improving Intensive Care Units (ICU) reliability in hospitals, this research tries to identify and analyze ICU’s process failure modes at the point of systematic approach to errors. Methods: In this descriptive research, data was gathered qualitatively by observations, document reviews, and Focus Group Discussions (FGDs) with the process owners in two selected ICUs in Tehran in 2014. But, data analysis was quantitative, based on failures’ Risk Priority Number (RPN) at the base of Failure Modes and Effects Analysis (FMEA) method used. Besides, some causes of failures were analyzed by qualitative Eindhoven Classification Model (ECM). Results: Through FMEA methodology, 378 potential failure modes from 180 ICU activities in hospital A and 184 potential failures from 99 ICU activities in hospital B were identified and evaluated. Then with 90% reliability (RPN≥100), totally 18 failures in hospital A and 42 ones in hospital B were identified as non-acceptable risks and then their causes were analyzed by ECM. Conclusions: Applying of modified PFMEA for improving two selected ICUs’ processes reliability in two different kinds of hospitals shows that this method empowers staff to identify, evaluate, prioritize and analyze all potential failure modes and also make them eager to identify their causes, recommend corrective actions and even participate in improving process without feeling blamed by top management. Moreover, by combining FMEA and ECM, team members can easily identify failure causes at the point of health care perspectives. PMID:27157162

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

PubMed Central

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

2016-01-01

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

Location Dependency and Antenna/Body/Sensor-Lead Interaction Effects in a Cell-Phone Based GSM 1800 Telemedicine Link

DTIC Science & Technology

2001-10-25

The error-free requirement of today’s cell - phone based telemedicine systems demands investigations into the potential causes of service degradation...to the handset’s antenna can have on system performance Changes in lead orientation in the near field of the radiating unit ( cell - phone & antenna

Classification of drugs with different risk profiles.

PubMed

Saedder, Eva Aggerholm; Brock, Birgitte; Nielsen, Lars Peter; Bonnerup, Dorthe Krogsgaard; Lisby, Marianne

2015-08-01

A risk stratification approach is needed to identify patients at high risk of medication errors and a resulting high need of medication review. The aim of this study was to perform risk stratification (distinguishing between low-risk, medium-risk and high-risk drugs) for drugs found to cause serious adverse reactions due to medication errors. The study employed a modified Delphi technique. Drugs from a systematic literature search were included into two rounds of a Delphi process. A panel of experts was asked to evaluate each identified drug's potential for harm and for clinically relevant drug-drug interactions on a scale from 1 (low risk) to 9 (high risk). A total of 36 experts were appointed to serve on the panel. Consensus was reached for 29/57 (51%) drugs or drug classes that cause harm, and for 32/57 (56%) of the drugs or drug classes that cause interactions. For the remaining drugs, a decision was made based on the median score. Two lists, one stating the drugs' potential for causing harm and the other stating clinically relevant drug-drug interactions, were stratified into low-risk, medium-risk and high-risk drugs. Based on a modified Delphi technique, we created two lists of drugs stratified into a low-risk, a medium-risk and a high-risk group of clinically relevant interactions or risk of harm to patients. The lists could be incorporated into a risk-scoring tool that stratifies the performance of medication reviews according to patients' risk of experiencing adverse reactions. none. not relevant.

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.

Acceptance threshold theory can explain occurrence of homosexual behaviour.

PubMed

Engel, Katharina C; Männer, Lisa; Ayasse, Manfred; Steiger, Sandra

2015-01-01

Same-sex sexual behaviour (SSB) has been documented in a wide range of animals, but its evolutionary causes are not well understood. Here, we investigated SSB in the light of Reeve's acceptance threshold theory. When recognition is not error-proof, the acceptance threshold used by males to recognize potential mating partners should be flexibly adjusted to maximize the fitness pay-off between the costs of erroneously accepting males and the benefits of accepting females. By manipulating male burying beetles' search time for females and their reproductive potential, we influenced their perceived costs of making an acceptance or rejection error. As predicted, when the costs of rejecting females increased, males exhibited more permissive discrimination decisions and showed high levels of SSB; when the costs of accepting males increased, males were more restrictive and showed low levels of SSB. Our results support the idea that in animal species, in which the recognition cues of females and males overlap to a certain degree, SSB is a consequence of an adaptive discrimination strategy to avoid the costs of making rejection errors. © 2015 The Author(s) Published by the Royal Society. All rights reserved.

Universal Capacitance Model for Real-Time Biomass in Cell Culture.

PubMed

Konakovsky, Viktor; Yagtu, Ali Civan; Clemens, Christoph; Müller, Markus Michael; Berger, Martina; Schlatter, Stefan; Herwig, Christoph

2015-09-02

: Capacitance probes have the potential to revolutionize bioprocess control due to their safe and robust use and ability to detect even the smallest capacitors in the form of biological cells. Several techniques have evolved to model biomass statistically, however, there are problems with model transfer between cell lines and process conditions. Errors of transferred models in the declining phase of the culture range for linear models around +100% or worse, causing unnecessary delays with test runs during bioprocess development. The goal of this work was to develop one single universal model which can be adapted by considering a potentially mechanistic factor to estimate biomass in yet untested clones and scales. The novelty of this work is a methodology to select sensitive frequencies to build a statistical model which can be shared among fermentations with an error between 9% and 38% (mean error around 20%) for the whole process, including the declining phase. A simple linear factor was found to be responsible for the transferability of biomass models between cell lines, indicating a link to their phenotype or physiology.

Parallel computers - Estimate errors caused by imprecise data

NASA Technical Reports Server (NTRS)

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

1991-01-01

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

Estimation of shortwave hemispherical reflectance (albedo) from bidirectionally reflected radiance data

NASA Technical Reports Server (NTRS)

Starks, Patrick J.; Norman, John M.; Blad, Blaine L.; Walter-Shea, Elizabeth A.; Walthall, Charles L.

1991-01-01

An equation for estimating albedo from bidirectional reflectance data is proposed. The estimates of albedo are found to be greater than values obtained with simultaneous pyranometer measurements. Particular attention is given to potential sources of systematic errors including extrapolation of bidirectional reflectance data out to a view zenith angle of 90 deg, the use of inappropriate weighting coefficients in the numerator of the albedo equation, surface shadowing caused by the A-frame instrumentation used to measure the incoming and outgoing radiation fluxes, errors in estimates of the denominator of the proposed albedo equation, and a 'hot spot' contribution in bidirectional data measured by a modular multiband radiometer.

Covariate Measurement Error Correction Methods in Mediation Analysis with Failure Time Data

PubMed Central

Zhao, Shanshan

2014-01-01

Summary Mediation analysis is important for understanding the mechanisms whereby one variable causes changes in another. Measurement error could obscure the ability of the potential mediator to explain such changes. This paper focuses on developing correction methods for measurement error in the mediator with failure time outcomes. We consider a broad definition of measurement error, including technical error and error associated with temporal variation. The underlying model with the ‘true’ mediator is assumed to be of the Cox proportional hazards model form. The induced hazard ratio for the observed mediator no longer has a simple form independent of the baseline hazard function, due to the conditioning event. We propose a mean-variance regression calibration approach and a follow-up time regression calibration approach, to approximate the partial likelihood for the induced hazard function. Both methods demonstrate value in assessing mediation effects in simulation studies. These methods are generalized to multiple biomarkers and to both case-cohort and nested case-control sampling design. We apply these correction methods to the Women's Health Initiative hormone therapy trials to understand the mediation effect of several serum sex hormone measures on the relationship between postmenopausal hormone therapy and breast cancer risk. PMID:25139469

Covariate measurement error correction methods in mediation analysis with failure time data.

PubMed

Zhao, Shanshan; Prentice, Ross L

2014-12-01

Mediation analysis is important for understanding the mechanisms whereby one variable causes changes in another. Measurement error could obscure the ability of the potential mediator to explain such changes. This article focuses on developing correction methods for measurement error in the mediator with failure time outcomes. We consider a broad definition of measurement error, including technical error, and error associated with temporal variation. The underlying model with the "true" mediator is assumed to be of the Cox proportional hazards model form. The induced hazard ratio for the observed mediator no longer has a simple form independent of the baseline hazard function, due to the conditioning event. We propose a mean-variance regression calibration approach and a follow-up time regression calibration approach, to approximate the partial likelihood for the induced hazard function. Both methods demonstrate value in assessing mediation effects in simulation studies. These methods are generalized to multiple biomarkers and to both case-cohort and nested case-control sampling designs. We apply these correction methods to the Women's Health Initiative hormone therapy trials to understand the mediation effect of several serum sex hormone measures on the relationship between postmenopausal hormone therapy and breast cancer risk. © 2014, The International Biometric Society.

Errors in otology.

PubMed

Kartush, J M

1996-11-01

Practicing medicine successfully requires that errors in diagnosis and treatment be minimized. Malpractice laws encourage litigators to ascribe all medical errors to incompetence and negligence. There are, however, many other causes of unintended outcomes. This article describes common causes of errors and suggests ways to minimize mistakes in otologic practice. Widespread dissemination of knowledge about common errors and their precursors can reduce the incidence of their occurrence. Consequently, laws should be passed to allow for a system of non-punitive, confidential reporting of errors and "near misses" that can be shared by physicians nationwide.

Death Certification Errors and the Effect on Mortality Statistics.

PubMed

McGivern, Lauri; Shulman, Leanne; Carney, Jan K; Shapiro, Steven; Bundock, Elizabeth

Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non-Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics. We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates. Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P < .001). Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code. Error rates on death certificates in Vermont are high and extend to ICD-10 coding, thereby affecting national mortality statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.

Fault Injection Techniques and Tools

NASA Technical Reports Server (NTRS)

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

1997-01-01

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

The current and ideal state of anatomic pathology patient safety.

PubMed

Raab, Stephen Spencer

2014-01-01

An anatomic pathology diagnostic error may be secondary to a number of active and latent technical and/or cognitive components, which may occur anywhere along the total testing process in clinical and/or laboratory domains. For the pathologist interpretive steps of diagnosis, we examine Kahneman's framework of slow and fast thinking to explain different causes of error in precision (agreement) and in accuracy (truth). The pathologist cognitive diagnostic process involves image pattern recognition and a slow thinking error may be caused by the application of different rationally-constructed mental maps of image criteria/patterns by different pathologists. This type of error is partly related to a system failure in standardizing the application of these maps. A fast thinking error involves the flawed leap from image pattern to incorrect diagnosis. In the ideal state, anatomic pathology systems would target these cognitive error causes as well as the technical latent factors that lead to error.

A root cause analysis project in a medication safety course.

PubMed

Schafer, Jason J

2012-08-10

To develop, implement, and evaluate team-based root cause analysis projects as part of a required medication safety course for second-year pharmacy students. Lectures, in-class activities, and out-of-class reading assignments were used to develop students' medication safety skills and introduce them to the culture of medication safety. Students applied these skills within teams by evaluating cases of medication errors using root cause analyses. Teams also developed error prevention strategies and formally presented their findings. Student performance was assessed using a medication errors evaluation rubric. Of the 211 students who completed the course, the majority performed well on root cause analysis assignments and rated them favorably on course evaluations. Medication error evaluation and prevention was successfully introduced in a medication safety course using team-based root cause analysis projects.

Estimating Population Cause-Specific Mortality Fractions from in-Hospital Mortality: Validation of a New Method

PubMed Central

Murray, Christopher J. L; Lopez, Alan D; Barofsky, Jeremy T; Bryson-Cahn, Chloe; Lozano, Rafael

2007-01-01

Background Cause-of-death data for many developing countries are not available. Information on deaths in hospital by cause is available in many low- and middle-income countries but is not a representative sample of deaths in the population. We propose a method to estimate population cause-specific mortality fractions (CSMFs) using data already collected in many middle-income and some low-income developing nations, yet rarely used: in-hospital death records. Methods and Findings For a given cause of death, a community's hospital deaths are equal to total community deaths multiplied by the proportion of deaths occurring in hospital. If we can estimate the proportion dying in hospital, we can estimate the proportion dying in the population using deaths in hospital. We propose to estimate the proportion of deaths for an age, sex, and cause group that die in hospital from the subset of the population where vital registration systems function or from another population. We evaluated our method using nearly complete vital registration (VR) data from Mexico 1998–2005, which records whether a death occurred in a hospital. In this validation test, we used 45 disease categories. We validated our method in two ways: nationally and between communities. First, we investigated how the method's accuracy changes as we decrease the amount of Mexican VR used to estimate the proportion of each age, sex, and cause group dying in hospital. Decreasing VR data used for this first step from 100% to 9% produces only a 12% maximum relative error between estimated and true CSMFs. Even if Mexico collected full VR information only in its capital city with 9% of its population, our estimation method would produce an average relative error in CSMFs across the 45 causes of just over 10%. Second, we used VR data for the capital zone (Distrito Federal and Estado de Mexico) and estimated CSMFs for the three lowest-development states. Our estimation method gave an average relative error of 20%, 23%, and 31% for Guerrero, Chiapas, and Oaxaca, respectively. Conclusions Where accurate International Classification of Diseases (ICD)-coded cause-of-death data are available for deaths in hospital and for VR covering a subset of the population, we demonstrated that population CSMFs can be estimated with low average error. In addition, we showed in the case of Mexico that this method can substantially reduce error from biased hospital data, even when applied to areas with widely different levels of development. For countries with ICD-coded deaths in hospital, this method potentially allows the use of existing data to inform health policy. PMID:18031195

An Examination of the Causes and Solutions to Eyewitness Error

PubMed Central

Wise, Richard A.; Sartori, Giuseppe; Magnussen, Svein; Safer, Martin A.

2014-01-01

Eyewitness error is one of the leading causes of wrongful convictions. In fact, the American Psychological Association estimates that one in three eyewitnesses make an erroneous identification. In this review, we look briefly at some of the causes of eyewitness error. We examine what jurors, judges, attorneys, law officers, and experts from various countries know about eyewitness testimony and memory, and if they have the requisite knowledge and skills to accurately assess eyewitness testimony. We evaluate whether legal safeguards such as voir dire, motion-to-suppress an identification, cross-examination, jury instructions, and eyewitness expert testimony are effective in identifying eyewitness errors. Lastly, we discuss solutions to eyewitness error. PMID:25165459

Precise method of compensating radiation-induced errors in a hot-cathode-ionization gauge with correcting electrode

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

Saeki, Hiroshi, E-mail: saeki@spring8.or.jp; Magome, Tamotsu, E-mail: saeki@spring8.or.jp

2014-10-06

To compensate pressure-measurement errors caused by a synchrotron radiation environment, a precise method using a hot-cathode-ionization-gauge head with correcting electrode, was developed and tested in a simulation experiment with excess electrons in the SPring-8 storage ring. This precise method to improve the measurement accuracy, can correctly reduce the pressure-measurement errors caused by electrons originating from the external environment, and originating from the primary gauge filament influenced by spatial conditions of the installed vacuum-gauge head. As the result of the simulation experiment to confirm the performance reducing the errors caused by the external environment, the pressure-measurement error using this method wasmore » approximately less than several percent in the pressure range from 10{sup −5} Pa to 10{sup −8} Pa. After the experiment, to confirm the performance reducing the error caused by spatial conditions, an additional experiment was carried out using a sleeve and showed that the improved function was available.« less

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.

Assessment of surface turbulent fluxes using geostationary satellite surface skin temperatures and a mixed layer planetary boundary layer scheme

NASA Technical Reports Server (NTRS)

Diak, George R.; Stewart, Tod R.

1989-01-01

A method is presented for evaluating the fluxes of sensible and latent heating at the land surface, using satellite-measured surface temperature changes in a composite surface layer-mixed layer representation of the planetary boundary layer. The basic prognostic model is tested by comparison with synoptic station information at sites where surface evaporation climatology is well known. The remote sensing version of the model, using satellite-measured surface temperature changes, is then used to quantify the sharp spatial gradient in surface heating/evaporation across the central United States. An error analysis indicates that perhaps five levels of evaporation are recognizable by these methods and that the chief cause of error is the interaction of errors in the measurement of surface temperature change with errors in the assigment of surface roughness character. Finally, two new potential methods for remote sensing of the land-surface energy balance are suggested which will relay on space-borne instrumentation planned for the 1990s.

Linear error analysis of slope-area discharge determinations

USGS Publications Warehouse

Kirby, W.H.

1987-01-01

The slope-area method can be used to calculate peak flood discharges when current-meter measurements are not possible. This calculation depends on several quantities, such as water-surface fall, that are subject to large measurement errors. Other critical quantities, such as Manning's n, are not even amenable to direct measurement but can only be estimated. Finally, scour and fill may cause gross discrepancies between the observed condition of the channel and the hydraulic conditions during the flood peak. The effects of these potential errors on the accuracy of the computed discharge have been estimated by statistical error analysis using a Taylor-series approximation of the discharge formula and the well-known formula for the variance of a sum of correlated random variates. The resultant error variance of the computed discharge is a weighted sum of covariances of the various observational errors. The weights depend on the hydraulic and geometric configuration of the channel. The mathematical analysis confirms the rule of thumb that relative errors in computed discharge increase rapidly when velocity heads exceed the water-surface fall, when the flow field is expanding and when lateral velocity variation (alpha) is large. It also confirms the extreme importance of accurately assessing the presence of scour or fill. ?? 1987.

Acetaminophen attenuates error evaluation in cortex.

PubMed

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

2016-06-01

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. © The Author (2016). Published by Oxford University Press. For Permissions, please email: journals.permissions@oup.com.

A design approach for improving the performance of single-grid planar retarding potential analyzers

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

Davidson, R. L.; Earle, G. D.

2011-01-15

Planar retarding potential analyzers (RPAs) have a long flight history and have been included on numerous spaceflight missions including Dynamics Explorer, the Defense Meteorological Satellite Program, and the Communications/Navigation Outage Forecast System. RPAs allow for simultaneous measurement of plasma composition, density, temperature, and the component of the velocity vector normal to the aperture plane. Internal conductive grids are used to approximate ideal potential planes within the instrument, but these grids introduce perturbations to the potential map inside the RPA and cause errors in the measurement of the parameters listed above. A numerical technique is presented herein for minimizing these gridmore » errors for a specific mission by varying the depth and spacing of the grid wires. The example mission selected concentrates on plasma dynamics near the sunset terminator in the equatorial region. The international reference ionosphere model is used to discern the average conditions expected for this mission, and a numerical model of the grid-particle interaction is used to choose a grid design that will best fulfill the mission goals.« less

Metabolic evaluation of children with global developmental delay.

PubMed

Eun, So-Hee; Hahn, Si Houn

2015-04-01

Global developmental delay (GDD) is a relatively common early-onset chronic neurological condition, which may have prenatal, perinatal, postnatal, or undetermined causes. Family history, physical and neurological examinations, and detailed history of environmental risk factors might suggest a specific disease. However, diagnostic laboratory tests, brain imaging, and other evidence-based evaluations are necessary in most cases to elucidate the causes. Diagnosis of GDD has recently improved because of remarkable advances in genetic technology, but this is an exhaustive and expensive evaluation that may not lead to therapeutic benefits in the majority of GDD patients. Inborn metabolic errors are one of the main targets for the treatment of GDD, although only a small proportion of GDD patients have this type of error. Nevertheless, diagnosis is often challenging because the phenotypes of many genetic or metabolic diseases often overlap, and their clinical spectra are much broader than currently known. Appropriate and cost-effective strategies including up-to-date information for the early identification of the "treatable" causes of GDD are needed for the development of well-timed therapeutic applications with the potential to improve neurodevelopmental outcomes.

Advancing the research agenda for diagnostic error reduction.

PubMed

Zwaan, Laura; Schiff, Gordon D; Singh, Hardeep

2013-10-01

Diagnostic errors remain an underemphasised and understudied area of patient safety research. We briefly summarise the methods that have been used to conduct research on epidemiology, contributing factors and interventions related to diagnostic error and outline directions for future research. Research methods that have studied epidemiology of diagnostic error provide some estimate on diagnostic error rates. However, there appears to be a large variability in the reported rates due to the heterogeneity of definitions and study methods used. Thus, future methods should focus on obtaining more precise estimates in different settings of care. This would lay the foundation for measuring error rates over time to evaluate improvements. Research methods have studied contributing factors for diagnostic error in both naturalistic and experimental settings. Both approaches have revealed important and complementary information. Newer conceptual models from outside healthcare are needed to advance the depth and rigour of analysis of systems and cognitive insights of causes of error. While the literature has suggested many potentially fruitful interventions for reducing diagnostic errors, most have not been systematically evaluated and/or widely implemented in practice. Research is needed to study promising intervention areas such as enhanced patient involvement in diagnosis, improving diagnosis through the use of electronic tools and identification and reduction of specific diagnostic process 'pitfalls' (eg, failure to conduct appropriate diagnostic evaluation of a breast lump after a 'normal' mammogram). The last decade of research on diagnostic error has made promising steps and laid a foundation for more rigorous methods to advance the field.

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.

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

PubMed

Stultz, Jeremy S; Nahata, Milap C

2015-07-01

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

Errors Analysis of Students in Mathematics Department to Learn Plane Geometry

NASA Astrophysics Data System (ADS)

Mirna, M.

2018-04-01

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

Rapid, Accurate, and Non-Invasive Measurement of Zebrafish Axial Length and Other Eye Dimensions Using SD-OCT Allows Longitudinal Analysis of Myopia and Emmetropization

PubMed Central

Collery, Ross F.; Veth, Kerry N.; Dubis, Adam M.; Carroll, Joseph; Link, Brian A.

2014-01-01

Refractive errors in vision can be caused by aberrant axial length of the eye, irregular corneal shape, or lens abnormalities. Causes of eye length overgrowth include multiple genetic loci, and visual parameters. We evaluate zebrafish as a potential animal model for studies of the genetic, cellular, and signaling basis of emmetropization and myopia. Axial length and other eye dimensions of zebrafish were measured using spectral domain-optical coherence tomography (SD-OCT). We used ocular lens and body metrics to normalize and compare eye size and relative refractive error (difference between observed retinal radial length and controls) in wild-type and lrp2 zebrafish. Zebrafish were dark-reared to assess effects of visual deprivation on eye size. Two relative measurements, ocular axial length to body length and axial length to lens diameter, were found to accurately normalize comparisons of eye sizes between different sized fish (R2 = 0.9548, R2 = 0.9921). Ray-traced focal lengths of wild-type zebrafish lenses were equal to their retinal radii, while lrp2 eyes had longer retinal radii than focal lengths. Both genetic mutation (lrp2) and environmental manipulation (dark-rearing) caused elongated eye axes. lrp2 mutants had relative refractive errors of −0.327 compared to wild-types, and dark-reared wild-type fish had relative refractive errors of −0.132 compared to light-reared siblings. Therefore, zebrafish eye anatomy (axial length, lens radius, retinal radius) can be rapidly and accurately measured by SD-OCT, facilitating longitudinal studies of regulated eye growth and emmetropization. Specifically, genes homologous to human myopia candidates may be modified, inactivated or overexpressed in zebrafish, and myopia-sensitizing conditions used to probe gene-environment interactions. Our studies provide foundation for such investigations into genetic contributions that control eye size and impact refractive errors. PMID:25334040

Do calculation errors by nurses cause medication errors in clinical practice? A literature review.

PubMed

Wright, Kerri

2010-01-01

This review aims to examine the literature available to ascertain whether medication errors in clinical practice are the result of nurses' miscalculating drug dosages. The research studies highlighting poor calculation skills of nurses and student nurses have been tested using written drug calculation tests in formal classroom settings [Kapborg, I., 1994. Calculation and administration of drug dosage by Swedish nurses, student nurses and physicians. International Journal for Quality in Health Care 6(4): 389 -395; Hutton, M., 1998. Nursing Mathematics: the importance of application Nursing Standard 13(11): 35-38; Weeks, K., Lynne, P., Torrance, C., 2000. Written drug dosage errors made by students: the threat to clinical effectiveness and the need for a new approach. Clinical Effectiveness in Nursing 4, 20-29]; Wright, K., 2004. Investigation to find strategies to improve student nurses' maths skills. British Journal Nursing 13(21) 1280-1287; Wright, K., 2005. An exploration into the most effective way to teach drug calculation skills to nursing students. Nurse Education Today 25, 430-436], but there have been no reviews of the literature on medication errors in practice that specifically look to see whether the medication errors are caused by nurses' poor calculation skills. The databases Medline, CINAHL, British Nursing Index (BNI), Journal of American Medical Association (JAMA) and Archives and Cochrane reviews were searched for research studies or systematic reviews which reported on the incidence or causes of drug errors in clinical practice. In total 33 articles met the criteria for this review. There were no studies that examined nurses' drug calculation errors in practice. As a result studies and systematic reviews that investigated the types and causes of drug errors were examined to establish whether miscalculations by nurses were the causes of errors. The review found insufficient evidence to suggest that medication errors are caused by nurses' poor calculation skills. Of the 33 studies reviewed only five articles specifically recorded information relating to calculation errors and only two of these detected errors using the direct observational approach. The literature suggests that there are other more pressing aspects of nurses' preparation and administration of medications which are contributing to medication errors in practice that require more urgent attention and calls into question the current focus on calculation and numeracy skills of pre registration and qualified nurses (NMC 2008). However, more research is required into the calculation errors in practice. In particular there is a need for a direct observational study on paediatric nurses as there are presently none examining this area of practice.

Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors.

PubMed

Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne

2017-04-01

Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.

A software solution to dynamically reduce metallic distortions of electromagnetic tracking systems for image-guided surgery.

PubMed

Li, Mengfei; Hansen, Christian; Rose, Georg

2017-09-01

Electromagnetic tracking systems (EMTS) have achieved a high level of acceptance in clinical settings, e.g., to support tracking of medical instruments in image-guided interventions. However, tracking errors caused by movable metallic medical instruments and electronic devices are a critical problem which prevents the wider application of EMTS for clinical applications. We plan to introduce a method to dynamically reduce tracking errors caused by metallic objects in proximity to the magnetic sensor coil of the EMTS. We propose a method using ramp waveform excitation based on modeling the conductive distorter as a resistance-inductance circuit. Additionally, a fast data acquisition method is presented to speed up the refresh rate. With the current approach, the sensor's positioning mean error is estimated to be 3.4, 1.3 and 0.7 mm, corresponding to a distance between the sensor and center of the transmitter coils' array of up to 200, 150 and 100 mm, respectively. The sensor pose error caused by different medical instruments placed in proximity was reduced by the proposed method to a level lower than 0.5 mm in position and [Formula: see text] in orientation. By applying the newly developed fast data acquisition method, we achieved a system refresh rate up to approximately 12.7 frames per second. Our software-based approach can be integrated into existing medical EMTS seamlessly with no change in hardware. It improves the tracking accuracy of clinical EMTS when there is a metallic object placed near the sensor coil and has the potential to improve the safety and outcome of image-guided interventions.

Prototyping context-aware nursing support mobile system.

PubMed

Esashi, Misa; Nakano, Tomohiro; Onose, Nao; Sato, Kikue; Hikita, Tomoko; Hoya, Reiko; Okamoto, Kazuya; Ohboshi, Naoki; Kuroda, Tomohiro

2016-08-01

A context aware nursing support system to push right information to the right person at the right moment is the key to increase clinical safety under a computerized hospital. We prototyped a system which obtains context from positions of nurses and list of expected clinical procedures. A WoZ test showed that the proposed approach has potential to decrease incidents caused by information delivery error.

Communication errors in radiology - Pitfalls and how to avoid them.

PubMed

Waite, Stephen; Scott, Jinel Moore; Drexler, Ian; Martino, Jennifer; Legasto, Alan; Gale, Brian; Kolla, Srinivas

2018-06-07

Communication failures are a common cause of patient harm and malpractice claims against radiologists. In addition to overt communication breakdowns among providers, it is also important to address the quality of communication to optimize patient outcomes. In this review, we describe common communication failures and potential solutions providing a framework for radiologists to improve health care delivery. Copyright © 2018. Published by Elsevier Inc.

Beauty from the beast: Avoiding errors in responding to client questions.

PubMed

Waehler, Charles A; Grandy, Natalie M

2016-09-01

Those rare moments when clients ask direct questions of their therapists likely represent a point when they are particularly open to new considerations, thereby representing an opportunity for substantial therapeutic gains. However, clinical errors abound in this area because clients' questions often engender apprehension in therapists, causing therapists to respond with too little or too much information or shutting down the discussion prematurely. These response types can damage the therapeutic relationship, the psychotherapy process, or both. We explore the nature of these clinical errors in response to client questions by providing examples from our own clinical work, suggesting potential reasons why clinicians may not make optimal use of client questions, and discussing how the mixed psychological literature further complicates the issue. We also present four guidelines designed to help therapists, trainers, and supervisors respond constructively to clinical questions in order to create constructive interactions. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Analysis of Video-Based Microscopic Particle Trajectories Using Kalman Filtering

PubMed Central

Wu, Pei-Hsun; Agarwal, Ashutosh; Hess, Henry; Khargonekar, Pramod P.; Tseng, Yiider

2010-01-01

Abstract The fidelity of the trajectories obtained from video-based particle tracking determines the success of a variety of biophysical techniques, including in situ single cell particle tracking and in vitro motility assays. However, the image acquisition process is complicated by system noise, which causes positioning error in the trajectories derived from image analysis. Here, we explore the possibility of reducing the positioning error by the application of a Kalman filter, a powerful algorithm to estimate the state of a linear dynamic system from noisy measurements. We show that the optimal Kalman filter parameters can be determined in an appropriate experimental setting, and that the Kalman filter can markedly reduce the positioning error while retaining the intrinsic fluctuations of the dynamic process. We believe the Kalman filter can potentially serve as a powerful tool to infer a trajectory of ultra-high fidelity from noisy images, revealing the details of dynamic cellular processes. PMID:20550894

Postfabrication Phase Error Correction of Silicon Photonic Circuits by Single Femtosecond Laser Pulses

DOE PAGES

Bachman, Daniel; Chen, Zhijiang; Wang, Christopher; ...

2016-11-29

Phase errors caused by fabrication variations in silicon photonic integrated circuits are an important problem, which negatively impacts device yield and performance. This study reports our recent progress in the development of a method for permanent, postfabrication phase error correction of silicon photonic circuits based on femtosecond laser irradiation. Using beam shaping technique, we achieve a 14-fold enhancement in the phase tuning resolution of the method with a Gaussian-shaped beam compared to a top-hat beam. The large improvement in the tuning resolution makes the femtosecond laser method potentially useful for very fine phase trimming of silicon photonic circuits. Finally, wemore » also show that femtosecond laser pulses can directly modify silicon photonic devices through a SiO 2 cladding layer, making it the only permanent post-fabrication method that can tune silicon photonic circuits protected by an oxide cladding.« less

Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran.

PubMed

Haghighi, Mohammad Hosein Hayavi; Dehghani, Mohammad; Teshnizi, Saeid Hoseini; Mahmoodi, Hamid

2014-01-01

Accurate cause of death coding leads to organised and usable death information but there are some factors that influence documentation on death certificates and therefore affect the coding. We reviewed the role of documentation errors on the accuracy of death coding at Shahid Mohammadi Hospital (SMH), Bandar Abbas, Iran. We studied the death certificates of all deceased patients in SMH from October 2010 to March 2011. Researchers determined and coded the underlying cause of death on the death certificates according to the guidelines issued by the World Health Organization in Volume 2 of the International Statistical Classification of Diseases and Health Related Problems-10th revision (ICD-10). Necessary ICD coding rules (such as the General Principle, Rules 1-3, the modification rules and other instructions about death coding) were applied to select the underlying cause of death on each certificate. Demographic details and documentation errors were then extracted. Data were analysed with descriptive statistics and chi square tests. The accuracy rate of causes of death coding was 51.7%, demonstrating a statistically significant relationship (p=.001) with major errors but not such a relationship with minor errors. Factors that result in poor quality of Cause of Death coding in SMH are lack of coder training, documentation errors and the undesirable structure of death certificates.

Cortical dipole imaging using truncated total least squares considering transfer matrix error.

PubMed

Hori, Junichi; Takeuchi, Kosuke

2013-01-01

Cortical dipole imaging has been proposed as a method to visualize electroencephalogram in high spatial resolution. We investigated the inverse technique of cortical dipole imaging using a truncated total least squares (TTLS). The TTLS is a regularization technique to reduce the influence from both the measurement noise and the transfer matrix error caused by the head model distortion. The estimation of the regularization parameter was also investigated based on L-curve. The computer simulation suggested that the estimation accuracy was improved by the TTLS compared with Tikhonov regularization. The proposed method was applied to human experimental data of visual evoked potentials. We confirmed the TTLS provided the high spatial resolution of cortical dipole imaging.

Error detection and reduction in blood banking.

PubMed

Motschman, T L; Moore, S B

1996-12-01

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

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

NASA Astrophysics Data System (ADS)

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

2018-02-01

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

Solar Tracking Error Analysis of Fresnel Reflector

PubMed Central

Zheng, Jiantao; Yan, Junjie; Pei, Jie; Liu, Guanjie

2014-01-01

Depending on the rotational structure of Fresnel reflector, the rotation angle of the mirror was deduced under the eccentric condition. By analyzing the influence of the sun tracking rotation angle error caused by main factors, the change rule and extent of the influence were revealed. It is concluded that the tracking errors caused by the difference between the rotation axis and true north meridian, at noon, were maximum under certain conditions and reduced at morning and afternoon gradually. The tracking error caused by other deviations such as rotating eccentric, latitude, and solar altitude was positive at morning, negative at afternoon, and zero at a certain moment of noon. PMID:24895664

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

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

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

NASA Astrophysics Data System (ADS)

Priyani, H. A.; Ekawati, R.

2018-01-01

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

Knowledge of healthcare professionals about medication errors in hospitals

PubMed Central

Abdel-Latif, Mohamed M. M.

2016-01-01

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

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

PubMed Central

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

2015-01-01

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

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.

46 CFR 520.14 - Special permission.

Code of Federal Regulations, 2010 CFR

2010-10-01

... the Commission, in its discretion and for good cause shown, to permit increases or decreases in rates... its discretion and for good cause shown, permit departures from the requirements of this part. (b) Clerical errors. Typographical and/or clerical errors constitute good cause for the exercise of special...

46 CFR 520.14 - Special permission.

Code of Federal Regulations, 2011 CFR

2011-10-01

... the Commission, in its discretion and for good cause shown, to permit increases or decreases in rates... its discretion and for good cause shown, permit departures from the requirements of this part. (b) Clerical errors. Typographical and/or clerical errors constitute good cause for the exercise of special...

Probing the cosmic causes of errors in supercomputers

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

None

Cosmic rays from outer space are causing errors in supercomputers. The neutrons that pass through the CPU may be causing binary data to flip leading to incorrect calculations. Los Alamos National Laboratory has developed detectors to determine how much data is being corrupted by these cosmic particles.

Contagious error sources would need time travel to prevent quantum computation

NASA Astrophysics Data System (ADS)

Kalai, Gil; Kuperberg, Greg

2015-08-01

We consider an error model for quantum computing that consists of "contagious quantum germs" that can infect every output qubit when at least one input qubit is infected. Once a germ actively causes error, it continues to cause error indefinitely for every qubit it infects, with arbitrary quantum entanglement and correlation. Although this error model looks much worse than quasi-independent error, we show that it reduces to quasi-independent error with the technique of quantum teleportation. The construction, which was previously described by Knill, is that every quantum circuit can be converted to a mixed circuit with bounded quantum depth. We also consider the restriction of bounded quantum depth from the point of view of quantum complexity classes.

Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.

PubMed

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris; Bjørn, Brian; Lilja, Beth; Mogensen, Torben

2011-03-01

Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

Prevalence of refractive error and visual impairment among rural school-age children of Goro District, Gurage Zone, Ethiopia.

PubMed

Kedir, Jafer; Girma, Abonesh

2014-10-01

Refractive error is one of the major causes of blindness and visual impairment in children; but community based studies are scarce especially in rural parts of Ethiopia. So, this study aims to assess the prevalence of refractive error and its magnitude as a cause of visual impairment among school-age children of rural community. This community-based cross-sectional descriptive study was conducted from March 1 to April 30, 2009 in rural villages of Goro district of Gurage Zone, found south west of Addis Ababa, the capital of Ethiopia. A multistage cluster sampling method was used with simple random selection of representative villages in the district. Chi-Square and t-tests were used in the data analysis. A total of 570 school-age children (age 7-15) were evaluated, 54% boys and 46% girls. The prevalence of refractive error was 3.5% (myopia 2.6% and hyperopia 0.9%). Refractive error was the major cause of visual impairment accounting for 54% of all causes in the study group. No child was found wearing corrective spectacles during the study period. Refractive error was the commonest cause of visual impairment in children of the district, but no measures were taken to reduce the burden in the community. So, large scale community level screening for refractive error should be conducted and integrated with regular school eye screening programs. Effective strategies need to be devised to provide low cost corrective spectacles in the rural community.

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

PubMed

Kiymaz, Dilek; Koç, Zeliha

2018-03-01

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

Retrospective data on causes of childhood vision impairment in Eritrea.

PubMed

Gyawali, Rajendra; Bhayal, Bharat Kumar; Adhikary, Rabindra; Shrestha, Arjun; Sah, Rabindra Prasad

2017-11-22

Proper information on causes of childhood vision loss is essential in developing appropriate strategies and programs to address such causes. This study aimed at identifying the causes of vision loss in children attending the national referral eye hospital with the only pediatric ophthalmology service in Eritrea. A retrospective data review was conducted for all the children (< 16 years of age) who attended Berhan Aiyni National Referral Eye Hospital in five years period from January 2011 to December 2015. Causes of vision loss for children with vision impairment (recorded visual acuity less than 6/18 for distance in the better eye) was classified by the anatomical site affected and by underlying etiology based on the timing of the insult and causal factor. The medical record cards of 22,509 children were reviewed, of whom 249 (1.1%) were visually impaired. The mean age of the participants was 7.82 ± 5.43 years (range: one month to 16 years) and male to female ratio was 1:0.65. The leading causes of vision loss were cataract (19.7%), corneal scars (15.7%), refractive error and amblyopia (12.1%), optic atrophy (6.4%), phthisis bulbi (6.4%), aphakia (5.6%) and glaucoma (5.2%). Childhood factors including trauma were the leading causes identified (34.5%) whereas other causes included hereditary factors (4%), intrauterine factors (2.0%) and perinatal factors (4.4%). In 55.0% of the children, the underlying etiology could not be attributed. Over two-thirds (69.9%) of vision loss was potentially avoidable in nature. This study explored the causes of vision loss in Eritrean children using hospital based data. Cataract corneal opacities, refractive error and amblyopia, globe damage due to trauma, infection and nutritional deficiency, retinal disorders, and other congenital abnormalities were the leading causes of childhood vision impairment in children attending the tertiary eye hospital in Eritrea. As majority of the causes of vision loss was due to avoidable causes, we recommended primary level public health strategies to prevent ocular injuries, vitamin A deficiency, perinatal infections and retinopathy of prematurity as well as specialist pediatric eye care facilities for cataract, refractive errors, glaucoma and rehabilitative services to address childhood vision loss in Eritrea.

Preparations for Global Precipitation Measurement(GPM)Ground Validation

NASA Technical Reports Server (NTRS)

Bidwell, S. W.; Bibyk, I. K.; Duming, J. F.; Everett, D. F.; Smith, E. A.; Wolff, D. B.

2004-01-01

The Global Precipitation Measurement (GPM) program is an international partnership led by the National Aeronautics and Space Administration (NASA) and the Japan Aerospace Exploration Agency (JAXA). GPM will improve climate, weather, and hydro-meterorological forecasts through more frequent and more accurate measurement of precipitation across the globe. This paper describes the concept and the preparations for Ground Validation within the GPM program. Ground Validation (GV) plays a critical role in the program by investigating and quantitatively assessing the errors within the satellite retrievals. These quantitative estimates of retrieval errors will assist the scientific community by bounding the errors within their research products. The two fundamental requirements of the GPM Ground Validation program are: (1) error characterization of the precipitation retrievals and (2) continual improvement of the satellite retrieval algorithms. These two driving requirements determine the measurements, instrumentation, and location for ground observations. This paper describes GV plans for estimating the systematic and random components of retrieval error and for characterizing the spatial and temporal structure of the error. This paper describes the GPM program for algorithm improvement in which error models are developed and experimentally explored to uncover the physical causes of errors within the retrievals. GPM will ensure that information gained through Ground Validation is applied to future improvements in the spaceborne retrieval algorithms. This paper discusses the potential locations for validation measurement and research, the anticipated contributions of GPM's international partners, and the interaction of Ground Validation with other GPM program elements.

An investigation into false-negative transthoracic fine needle aspiration and core biopsy specimens.

PubMed

Minot, Douglas M; Gilman, Elizabeth A; Aubry, Marie-Christine; Voss, Jesse S; Van Epps, Sarah G; Tuve, Delores J; Sciallis, Andrew P; Henry, Michael R; Salomao, Diva R; Lee, Peter; Carlson, Stephanie K; Clayton, Amy C

2014-12-01

Transthoracic fine needle aspiration (TFNA)/core needle biopsy (CNB) under computed tomography (CT) guidance has proved useful in the assessment of pulmonary nodules. We sought to determine the TFNA false-negative (FN) rate at our institution and identify potential causes of FN diagnoses. Medical records were reviewed from 1,043 consecutive patients who underwent CT-guided TFNA with or without CNB of lung nodules over a 5-year time period (2003-2007). Thirty-seven FN cases of "negative" TFNA/CNB with malignant outcome were identified with 36 cases available for review, of which 35 had a corresponding CNB. Cases were reviewed independently (blinded to original diagnosis) by three pathologists with 15 age- and sex-matched positive and negative controls. Diagnosis (i.e., nondiagnostic, negative or positive for malignancy, atypical or suspicious) and qualitative assessments were recorded. Consensus diagnosis was suspicious or positive in 10 (28%) of 36 TFNA cases and suspicious in 1 (3%) of 35 CNB cases, indicating potential interpretive errors. Of the 11 interpretive errors (including both suspicious and positive cases), 8 were adenocarcinomas, 1 squamous cell carcinoma, 1 metastatic renal cell carcinoma, and 1 lymphoma. The remaining 25 FN cases (69.4%) were considered sampling errors and consisted of 7 adenocarcinomas, 3 nonsmall cell carcinomas, 3 lymphomas, 2 squamous cell carcinomas, and 2 renal cell carcinomas. Interpretive and sampling error cases were more likely to abut the pleura, while histopathologically, they tended to be necrotic and air-dried. The overall FN rate in this patient cohort is 3.5% (1.1% interpretive and 2.4% sampling errors). © 2014 Wiley Periodicals, Inc.

Selection Bias in Students' Evaluation of Teaching: Causes of Student Absenteeism and Its Consequences for Course Ratings and Rankings

ERIC Educational Resources Information Center

Wolbring, Tobias; Treischl, Edgar

2016-01-01

Systematic sampling error due to self-selection is a common topic in methodological research and a key challenge for every empirical study. Since selection bias is often not sufficiently considered as a potential flaw in research on and evaluations in higher education, the aim of this paper is to raise awareness for the topic using the case of…

Global magnitude of visual impairment caused by uncorrected refractive errors in 2004

PubMed Central

Pascolini, Donatella; Mariotti, Silvio P; Pokharel, Gopal P

2008-01-01

Abstract Estimates of the prevalence of visual impairment caused by uncorrected refractive errors in 2004 have been determined at regional and global levels for people aged 5 years and over from recent published and unpublished surveys. The estimates were based on the prevalence of visual acuity of less than 6/18 in the better eye with the currently available refractive correction that could be improved to equal to or better than 6/18 by refraction or pinhole. A total of 153 million people (range of uncertainty: 123 million to 184 million) are estimated to be visually impaired from uncorrected refractive errors, of whom eight million are blind. This cause of visual impairment has been overlooked in previous estimates that were based on best-corrected vision. Combined with the 161 million people visually impaired estimated in 2002 according to best-corrected vision, 314 million people are visually impaired from all causes: uncorrected refractive errors become the main cause of low vision and the second cause of blindness. Uncorrected refractive errors can hamper performance at school, reduce employability and productivity, and generally impair quality of life. Yet the correction of refractive errors with appropriate spectacles is among the most cost-effective interventions in eye health care. The results presented in this paper help to unearth a formerly hidden problem of public health dimensions and promote policy development and implementation, programmatic decision-making and corrective interventions, as well as stimulate research. PMID:18235892

In the Aftermath: Attitudes of Anesthesiologists to Supportive Strategies After an Unexpected Intraoperative Patient Death.

PubMed

Heard, Gaylene C; Thomas, Rowan D; Sanderson, Penelope M

2016-05-01

Although most anesthesiologists will have 1 catastrophic perioperative event or more during their careers, there has been little research on their attitudes to assistive strategies after the event. There are wide-ranging emotional consequences for anesthesiologists involved in an unexpected intraoperative patient death, particularly if the anesthesiologist made an error. We used a between-groups survey study design to ask whether there are different attitudes to assistive strategies when a hypothetical patient death is caused by a drug error versus not caused by an error. First, we explored attitudes to generalized supportive strategies. Second, we examined our hypothesis that the presence of an error causing the hypothetical patient death would increase the perceived social stigma and self-stigma of help-seeking. Finally, we examined the strategies to assist help-seeking. An anonymous, mailed, self-administered survey was conducted with 1600 consultant anesthesiologists in Australia on the mailing list of the Australian and New Zealand College of Anaesthetists. The participants were randomized into "error" versus "no-error" groups for the hypothetical scenario of patient death due to anaphylaxis. Nonparametric, descriptive, parametric, and inferential tests were used for data analysis. P' is used where P values were corrected for multiple comparisons. There was a usable response rate of 48.9%. When an error had caused the hypothetical patient death, participants were more likely to agree with 4 of the 5 statements about support, including need for time off (P' = 0.003), counseling (P' < 0.001), a formal strategy for assistance (P' < 0.001), and the anesthesiologist not performing further cases that day (P' = 0.047). There were no differences between groups in perceived self-stigma (P = 0.98) or social stigma (P = 0.15) of seeking counseling, whether or not an error had caused the hypothetical patient death. Finally, when an error had caused the patient death, participants were more likely to agree with 2 of the 5 statements about help-seeking, including the need for a formal, hospital-based process that provides information on where to obtain professional counseling (P' = 0.006) and the availability of after-hours counseling services (P' = 0.035). Our participants were more likely to agree with assistive strategies such as not performing further work that day, time off, counseling, formal support strategies, and availability of after-hours counseling services, when the hypothetical patient death from anaphylaxis was due to an error. The perceived stigma toward attending counseling was not affected by the presence or absence of an error as the cause of the patient death, disproving our hypothesis.

From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.

PubMed

Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A

2003-02-01

The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1). errors inevitably occur and usually derive from faulty system design, not from negligence; (2). accident prevention should be an ongoing process based on open and full reporting; (3). major accidents are only the "tip of the iceberg" of processes that indicate possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff.

From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care

PubMed Central

Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A

2003-01-01



 The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1) errors inevitably occur and usually derive from faulty system design, not from negligence; (2) accident prevention should be an ongoing process based on open and full reporting; (3) major accidents are only the "tip of the iceberg" of processes that indicate possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff. PMID:12571343

Mutagenic cost of ribonucleotides in bacterial DNA

PubMed Central

Schroeder, Jeremy W.; Randall, Justin R.; Hirst, William G.; O’Donnell, Michael E.; Simmons, Lyle A.

2017-01-01

Replicative DNA polymerases misincorporate ribonucleoside triphosphates (rNTPs) into DNA approximately once every 2,000 base pairs synthesized. Ribonucleotide excision repair (RER) removes ribonucleoside monophosphates (rNMPs) from genomic DNA, replacing the error with the appropriate deoxyribonucleoside triphosphate (dNTP). Ribonucleotides represent a major threat to genome integrity with the potential to cause strand breaks. Furthermore, it has been shown in the bacterium Bacillus subtilis that loss of RER increases spontaneous mutagenesis. Despite the high rNTP error rate and the effect on genome integrity, the mechanism underlying mutagenesis in RER-deficient bacterial cells remains unknown. We performed mutation accumulation lines and genome-wide mutational profiling of B. subtilis lacking RNase HII, the enzyme that incises at single rNMP residues initiating RER. We show that loss of RER in B. subtilis causes strand- and sequence-context–dependent GC → AT transitions. Using purified proteins, we show that the replicative polymerase DnaE is mutagenic within the sequence context identified in RER-deficient cells. We also found that DnaE does not perform strand displacement synthesis. Given the use of nucleotide excision repair (NER) as a backup pathway for RER in RNase HII-deficient cells and the known mutagenic profile of DnaE, we propose that misincorporated ribonucleotides are removed by NER followed by error-prone resynthesis with DnaE. PMID:29078353

Hyperspectral Analysis of Soil Total Nitrogen in Subsided Land Using the Local Correlation Maximization-Complementary Superiority (LCMCS) Method.

PubMed

Lin, Lixin; Wang, Yunjia; Teng, Jiyao; Xi, Xiuxiu

2015-07-23

The measurement of soil total nitrogen (TN) by hyperspectral remote sensing provides an important tool for soil restoration programs in areas with subsided land caused by the extraction of natural resources. This study used the local correlation maximization-complementary superiority method (LCMCS) to establish TN prediction models by considering the relationship between spectral reflectance (measured by an ASD FieldSpec 3 spectroradiometer) and TN based on spectral reflectance curves of soil samples collected from subsided land which is determined by synthetic aperture radar interferometry (InSAR) technology. Based on the 1655 selected effective bands of the optimal spectrum (OSP) of the first derivate differential of reciprocal logarithm ([log{1/R}]'), (correlation coefficients, p < 0.01), the optimal model of LCMCS method was obtained to determine the final model, which produced lower prediction errors (root mean square error of validation [RMSEV] = 0.89, mean relative error of validation [MREV] = 5.93%) when compared with models built by the local correlation maximization (LCM), complementary superiority (CS) and partial least squares regression (PLS) methods. The predictive effect of LCMCS model was optional in Cangzhou, Renqiu and Fengfeng District. Results indicate that the LCMCS method has great potential to monitor TN in subsided lands caused by the extraction of natural resources including groundwater, oil and coal.

Selective and divided attention modulates auditory-vocal integration in the processing of pitch feedback errors.

PubMed

Liu, Ying; Hu, Huijing; Jones, Jeffery A; Guo, Zhiqiang; Li, Weifeng; Chen, Xi; Liu, Peng; Liu, Hanjun

2015-08-01

Speakers rapidly adjust their ongoing vocal productions to compensate for errors they hear in their auditory feedback. It is currently unclear what role attention plays in these vocal compensations. This event-related potential (ERP) study examined the influence of selective and divided attention on the vocal and cortical responses to pitch errors heard in auditory feedback regarding ongoing vocalisations. During the production of a sustained vowel, participants briefly heard their vocal pitch shifted up two semitones while they actively attended to auditory or visual events (selective attention), or both auditory and visual events (divided attention), or were not told to attend to either modality (control condition). The behavioral results showed that attending to the pitch perturbations elicited larger vocal compensations than attending to the visual stimuli. Moreover, ERPs were likewise sensitive to the attentional manipulations: P2 responses to pitch perturbations were larger when participants attended to the auditory stimuli compared to when they attended to the visual stimuli, and compared to when they were not explicitly told to attend to either the visual or auditory stimuli. By contrast, dividing attention between the auditory and visual modalities caused suppressed P2 responses relative to all the other conditions and caused enhanced N1 responses relative to the control condition. These findings provide strong evidence for the influence of attention on the mechanisms underlying the auditory-vocal integration in the processing of pitch feedback errors. In addition, selective attention and divided attention appear to modulate the neurobehavioral processing of pitch feedback errors in different ways. © 2015 Federation of European Neuroscience Societies and John Wiley & Sons Ltd.

Constrained motion estimation-based error resilient coding for HEVC

NASA Astrophysics Data System (ADS)

Guo, Weihan; Zhang, Yongfei; Li, Bo

2018-04-01

Unreliable communication channels might lead to packet losses and bit errors in the videos transmitted through it, which will cause severe video quality degradation. This is even worse for HEVC since more advanced and powerful motion estimation methods are introduced to further remove the inter-frame dependency and thus improve the coding efficiency. Once a Motion Vector (MV) is lost or corrupted, it will cause distortion in the decoded frame. More importantly, due to motion compensation, the error will propagate along the motion prediction path, accumulate over time, and significantly degrade the overall video presentation quality. To address this problem, we study the problem of encoder-sider error resilient coding for HEVC and propose a constrained motion estimation scheme to mitigate the problem of error propagation to subsequent frames. The approach is achieved by cutting off MV dependencies and limiting the block regions which are predicted by temporal motion vector. The experimental results show that the proposed method can effectively suppress the error propagation caused by bit errors of motion vector and can improve the robustness of the stream in the bit error channels. When the bit error probability is 10-5, an increase of the decoded video quality (PSNR) by up to1.310dB and on average 0.762 dB can be achieved, compared to the reference HEVC.

[Allocation of attentional resource and monitoring processes under rapid serial visual presentation].

PubMed

Nishiura, K

1998-08-01

With the use of rapid serial visual presentation (RSVP), the present study investigated the cause of target intrusion errors and functioning of monitoring processes. Eighteen students participated in Experiment 1, and 24 in Experiment 2. In Experiment 1, different target intrusion errors were found depending on different kinds of letters --romaji, hiragana, and kanji. In Experiment 2, stimulus set size and context information were manipulated in an attempt to explore the cause of post-target intrusion errors. Results showed that as stimulus set size increased, the post-target intrusion errors also increased, but contextual information did not affect the errors. Results concerning mean report probability indicated that increased allocation of attentional resource to response-defining dimension was the cause of the errors. In addition, results concerning confidence rating showed that monitoring of temporal and contextual information was extremely accurate, but it was not so for stimulus information. These results suggest that attentional resource is different from monitoring resource.

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

NASA Astrophysics Data System (ADS)

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

2018-01-01

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

Modelling the spatial distribution of the nuisance mosquito species Anopheles plumbeus (Diptera: Culicidae) in the Netherlands.

PubMed

Ibañez-Justicia, Adolfo; Cianci, Daniela

2015-05-01

Landscape modifications, urbanization or changes of use of rural-agricultural areas can create more favourable conditions for certain mosquito species and therefore indirectly cause nuisance problems for humans. This could potentially result in mosquito-borne disease outbreaks when the nuisance is caused by mosquito species that can transmit pathogens. Anopheles plumbeus is a nuisance mosquito species and a potential malaria vector. It is one of the most frequently observed species in the Netherlands. Information on the distribution of this species is essential for risk assessments. The purpose of the study was to investigate the potential spatial distribution of An. plumbeus in the Netherlands. Random forest models were used to link the occurrence and the abundance of An. plumbeus with environmental features and to produce distribution maps in the Netherlands. Mosquito data were collected using a cross-sectional study design in the Netherlands, from April to October 2010-2013. The environmental data were obtained from satellite imagery and weather stations. Statistical measures (accuracy for the occurrence model and mean squared error for the abundance model) were used to evaluate the models performance. The models were externally validated. The maps show that forested areas (centre of the Netherlands) and the east of the country were predicted as suitable for An. plumbeus. In particular high suitability and high abundance was predicted in the south-eastern provinces Limburg and North Brabant. Elevation, precipitation, day and night temperature and vegetation indices were important predictors for calculating the probability of occurrence for An. plumbeus. The probability of occurrence, vegetation indices and precipitation were important for predicting its abundance. The AUC value was 0.73 and the error in the validation was 0.29; the mean squared error value was 0.12. The areas identified by the model as suitable and with high abundance of An. plumbeus, are consistent with the areas from which nuisance was reported. Our results can be helpful in the assessment of vector-borne disease risk.

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors

PubMed Central

Palmer, Katherine A; Shane, Rita; Wu, Cindy N; Bell, Douglas S; Diaz, Frank; Cook-Wiens, Galen; Jackevicius, Cynthia A

2016-01-01

Objective We sought to assess the potential of a widely available source of electronic medication data to prevent medication history errors and resultant inpatient order errors. Methods We used admission medication history (AMH) data from a recent clinical trial that identified 1017 AMH errors and 419 resultant inpatient order errors among 194 hospital admissions of predominantly older adult patients on complex medication regimens. Among the subset of patients for whom we could access current Surescripts electronic pharmacy claims data (SEPCD), two pharmacists independently assessed error severity and our main outcome, which was whether SEPCD (1) was unrelated to the medication error; (2) probably would not have prevented the error; (3) might have prevented the error; or (4) probably would have prevented the error. Results Seventy patients had both AMH errors and current, accessible SEPCD. SEPCD probably would have prevented 110 (35%) of 315 AMH errors and 46 (31%) of 147 resultant inpatient order errors. When we excluded the least severe medication errors, SEPCD probably would have prevented 99 (47%) of 209 AMH errors and 37 (61%) of 61 resultant inpatient order errors. SEPCD probably would have prevented at least one AMH error in 42 (60%) of 70 patients. Conclusion When current SEPCD was available for older adult patients on complex medication regimens, it had substantial potential to prevent AMH errors and resultant inpatient order errors, with greater potential to prevent more severe errors. Further study is needed to measure the benefit of SEPCD in actual use at hospital admission. PMID:26911817

FORTRAN Automated Code Evaluation System (faces) system documentation, version 2, mod 0. [error detection codes/user manuals (computer programs)

NASA Technical Reports Server (NTRS)

1975-01-01

A system is presented which processes FORTRAN based software systems to surface potential problems before they become execution malfunctions. The system complements the diagnostic capabilities of compilers, loaders, and execution monitors rather than duplicating these functions. Also, it emphasizes frequent sources of FORTRAN problems which require inordinate manual effort to identify. The principle value of the system is extracting small sections of unusual code from the bulk of normal sequences. Code structures likely to cause immediate or future problems are brought to the user's attention. These messages stimulate timely corrective action of solid errors and promote identification of 'tricky' code. Corrective action may require recoding or simply extending software documentation to explain the unusual technique.

Alkaptonuria--first inborn error of metabolism known for a century and new treatment option--preliminary report.

PubMed

Sykut-Cegielska, Jolanta

2015-01-01

Alkaptonuria is a rare inborn error of metabolism, identified over a century ago. But its basic pathomechanism (i.e. ochronosis) is still not completely explained. Though clinical onset of osteoarthropathy and complications from other organs (including: heart and blood vessels, skin, eyes, kidneys) occurs at adult age, the symptoms are progressive, cause severe pains and significantly limit everyday life of the patients. Until now no effective therapeutic methods have been known in alkaptonuria. Recently, thanks to an initiative of the international patient organization for alkaptonuria, a hope for a potential treatment availability, appears. So, alkaptonuria is an example of a role of multidysciplinary care, cooperation and ongoing progress in the area of rare diseases.

Retrospective analysis of refractive errors in children with vision impairment.

PubMed

Du, Jojo W; Schmid, Katrina L; Bevan, Jennifer D; Frater, Karen M; Ollett, Rhondelle; Hein, Bronwyn

2005-09-01

Emmetropization is the reduction in neonatal refractive errors that occurs after birth. Ocular disease may affect this process. We aimed to determine the relative frequency of ocular conditions causing vision impairment in the pediatric population and characterize the refractive anomalies present. We also compared the causes of vision impairment in children today to those between 1974 and 1981. Causes of vision impairment and refractive data of 872 children attending a pediatric low-vision clinic from 1985 to 2002 were retrospectively collated. As a result of associated impairments, refractive data were not available for 59 children. An analysis was made of the causes of vision impairment, the distribution of refractive errors in children with vision impairment, and the average type of refractive error for the most commonly seen conditions. We found that cortical or cerebral vision impairment (CVI) was the most common condition causing vision impairment, accounting for 27.6% of cases. This was followed by albinism (10.6%), retinopathy of prematurity (ROP; 7.0%), optic atrophy (6.2%), and optic nerve hypoplasia (5.3%). Vision impairment was associated with ametropia; fewer than 25% of the children had refractive errors < or = +/-1 D. The refractive error frequency plots (for 0 to 2-, 6 to 8-, and 12 to 14-year age bands) had a Gaussian distribution indicating that the emmetropization process was abnormal. The mean spherical equivalent refractive error of the children (n = 813) was +0.78 +/- 6.00 D with 0.94 +/- 1.24 D of astigmatism and 0.92 +/- 2.15 D of anisometropia. Most conditions causing vision impairment such as albinism were associated with low amounts of hyperopia. Moderate myopia was observed in children with ROP. The relative frequency of ocular conditions causing vision impairment in children has changed since the 1970s. Children with vision impairment often have an associated ametropia suggesting that the emmetropization system is also impaired.

ATC operational error analysis.

DOT National Transportation Integrated Search

1972-01-01

The primary causes of operational errors are discussed and the effects of these errors on an ATC system's performance are described. No attempt is made to specify possible error models for the spectrum of blunders that can occur although previous res...

Quality of death notification forms in North West Bank/Palestine: a descriptive study.

PubMed

Qaddumi, Jamal A S; Nazzal, Zaher; Yacoup, Allam R S; Mansour, Mahmoud

2017-04-11

The death notification forms (DNFs) are important documents. Thus, inability to fill it properly by physicians will affect the national mortality report and, consequently, the evidence-based decision making. The errors in filling DNFs are common all over the world and are different in types and causes. We aimed to evaluate the quality of DNFs in terms of completeness and types of errors in the cause of death section. A descriptive study was conducted to review 2707 DNFs in North West Bank/Palestine during the year 2012 using data abstraction sheets. SPSS 17.0 was used to show the frequency of major and minor errors committed in filling the DNFs. Surprisingly, only 1% of the examined DNFs had their cause of death section filled completely correct. The immediate cause of death was correctly identified in 5.9% of all DNFs and the underlying cause of death was correctly reported in 55.4% of them. The sequence was incorrect in 41.5% of the DNFs. The most frequently documented minor error was "Not writing Time intervals" error (97.0%). Almost all DNFs contained at least one minor or major error. This high percentage of errors may affect the mortality and morbidity statistics, public health research and the process of providing evidence for health policy. Training workshops on DNF completion for newly recruited employees and at the beginning of the residency program are recommended on a regular basis. As well, we recommend reviewing the national DNFs to simplify it and make it consistent with updated evidence-based guidelines and recommendation.

Performance Analysis: Work Control Events Identified January - August 2010

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

De Grange, C E; Freeman, J W; Kerr, C E

2011-01-14

This performance analysis evaluated 24 events that occurred at LLNL from January through August 2010. The analysis identified areas of potential work control process and/or implementation weaknesses and several common underlying causes. Human performance improvement and safety culture factors were part of the causal analysis of each event and were analyzed. The collective significance of all events in 2010, as measured by the occurrence reporting significance category and by the proportion of events that have been reported to the DOE ORPS under the ''management concerns'' reporting criteria, does not appear to have increased in 2010. The frequency of reporting inmore » each of the significance categories has not changed in 2010 compared to the previous four years. There is no change indicating a trend in the significance category and there has been no increase in the proportion of occurrences reported in the higher significance category. Also, the frequency of events, 42 events reported through August 2010, is not greater than in previous years and is below the average of 63 occurrences per year at LLNL since 2006. Over the previous four years, an average of 43% of the LLNL's reported occurrences have been reported as either ''management concerns'' or ''near misses.'' In 2010, 29% of the occurrences have been reported as ''management concerns'' or ''near misses.'' This rate indicates that LLNL is now reporting fewer ''management concern'' and ''near miss'' occurrences compared to the previous four years. From 2008 to the present, LLNL senior management has undertaken a series of initiatives to strengthen the work planning and control system with the primary objective to improve worker safety. In 2008, the LLNL Deputy Director established the Work Control Integrated Project Team to develop the core requirements and graded elements of an institutional work planning and control system. By the end of that year this system was documented and implementation had begun. In 2009, training of the workforce began and as of the time of this report more than 50% of authorized Integration Work Sheets (IWS) use the activity-based planning process. In 2010, LSO independently reviewed the work planning and control process and confirmed to the Laboratory that the Integrated Safety Management (ISM) System was implemented. LLNL conducted a cross-directorate management self-assessment of work planning and control and is developing actions to respond to the issues identified. Ongoing efforts to strengthen the work planning and control process and to improve the quality of LLNL work packages are in progress: completion of remaining actions in response to the 2009 DOE Office of Health, Safety, and Security (HSS) evaluation of LLNL's ISM System; scheduling more than 14 work planning and control self-assessments in FY11; continuing to align subcontractor work control with the Institutional work planning and control system; and continuing to maintain the electronic IWS application. The 24 events included in this analysis were caused by errors in the first four of the five ISMS functions. The most frequent cause was errors in analyzing the hazards (Function 2). The second most frequent cause was errors occurring when defining the work (Function 1), followed by errors during the performance of work (Function 4). Interestingly, very few errors in developing controls (Function 3) resulted in events. This leads one to conclude that if improvements are made to defining the scope of work and analyzing the potential hazards, LLNL may reduce the frequency or severity of events. Analysis of the 24 events resulted in the identification of ten common causes. Some events had multiple causes, resulting in the mention of 39 causes being identified for the 24 events. The most frequent cause was workers, supervisors, or experts believing they understood the work and the hazards but their understanding was incomplete. The second most frequent cause was unclear, incomplete or confusing documents directing the work. Together, these two causes were mentioned 17 times and contributed to 13 of the events. All of the events with the cause of ''workers, supervisors, or experts believing they understood the work and the hazards but their understanding was incomplete'' had this error in the first two ISMS functions: define the work and analyze the hazard. This means that these causes result in the scope of work being ill-defined or the hazard(s) improperly analyzed. Incomplete implementation of these functional steps leads to the hazards not being controlled. The causes are then manifested in events when the work is conducted. The process to operate safely relies on accurately defining the scope of work. This review has identified a number of examples of latent organizational weakness in the execution of work control processes.« less

Porous plug for reducing orifice induced pressure error in airfoils

NASA Technical Reports Server (NTRS)

Plentovich, Elizabeth B. (Inventor); Gloss, Blair B. (Inventor); Eves, John W. (Inventor); Stack, John P. (Inventor)

1988-01-01

A porous plug is provided for the reduction or elimination of positive error caused by the orifice during static pressure measurements of airfoils. The porous plug is press fitted into the orifice, thereby preventing the error caused either by fluid flow turning into the exposed orifice or by the fluid flow stagnating at the downstream edge of the orifice. In addition, the porous plug is made flush with the outer surface of the airfoil, by filing and polishing, to provide a smooth surface which alleviates the error caused by imperfections in the orifice. The porous plug is preferably made of sintered metal, which allows air to pass through the pores, so that the static pressure measurements can be made by remote transducers.

Multiple description distributed image coding with side information for mobile wireless transmission

NASA Astrophysics Data System (ADS)

Wu, Min; Song, Daewon; Chen, Chang Wen

2005-03-01

Multiple description coding (MDC) is a source coding technique that involves coding the source information into multiple descriptions, and then transmitting them over different channels in packet network or error-prone wireless environment to achieve graceful degradation if parts of descriptions are lost at the receiver. In this paper, we proposed a multiple description distributed wavelet zero tree image coding system for mobile wireless transmission. We provide two innovations to achieve an excellent error resilient capability. First, when MDC is applied to wavelet subband based image coding, it is possible to introduce correlation between the descriptions in each subband. We consider using such a correlation as well as potentially error corrupted description as side information in the decoding to formulate the MDC decoding as a Wyner Ziv decoding problem. If only part of descriptions is lost, however, their correlation information is still available, the proposed Wyner Ziv decoder can recover the description by using the correlation information and the error corrupted description as side information. Secondly, in each description, single bitstream wavelet zero tree coding is very vulnerable to the channel errors. The first bit error may cause the decoder to discard all subsequent bits whether or not the subsequent bits are correctly received. Therefore, we integrate the multiple description scalar quantization (MDSQ) with the multiple wavelet tree image coding method to reduce error propagation. We first group wavelet coefficients into multiple trees according to parent-child relationship and then code them separately by SPIHT algorithm to form multiple bitstreams. Such decomposition is able to reduce error propagation and therefore improve the error correcting capability of Wyner Ziv decoder. Experimental results show that the proposed scheme not only exhibits an excellent error resilient performance but also demonstrates graceful degradation over the packet loss rate.

Multiple indicators, multiple causes measurement error models

DOE PAGES

Tekwe, Carmen D.; Carter, Randy L.; Cullings, Harry M.; ...

2014-06-25

Multiple indicators, multiple causes (MIMIC) models are often employed by researchers studying the effects of an unobservable latent variable on a set of outcomes, when causes of the latent variable are observed. There are times, however, when the causes of the latent variable are not observed because measurements of the causal variable are contaminated by measurement error. The objectives of this study are as follows: (i) to develop a novel model by extending the classical linear MIMIC model to allow both Berkson and classical measurement errors, defining the MIMIC measurement error (MIMIC ME) model; (ii) to develop likelihood-based estimation methodsmore » for the MIMIC ME model; and (iii) to apply the newly defined MIMIC ME model to atomic bomb survivor data to study the impact of dyslipidemia and radiation dose on the physical manifestations of dyslipidemia. Finally, as a by-product of our work, we also obtain a data-driven estimate of the variance of the classical measurement error associated with an estimate of the amount of radiation dose received by atomic bomb survivors at the time of their exposure.« less

Influence of wheelchair front caster wheel on reverse directional stability.

PubMed

Guo, Songfeng; Cooper, Rory A; Corfman, Tom; Ding, Dan; Grindle, Garrett

2003-01-01

The purpose of this research was to study directional stability during reversing of rear-wheel drive, electric powered wheelchairs (EPW) under different initial front caster orientations. Specifically, the weight distribution differences caused by certain initial caster orientations were examined as a possible mechanism for causing directional instability that could lead to accidents. Directional stability was quantified by measuring the drive direction error of the EPW by a motion analysis system. The ground reaction forces were collected to determine the load on the front casters, as well as back-emf data to attain the speed of the motors. The drive direction error was found to be different for various initial caster orientations. Drive direction error was greatest when both casters were oriented 90 degrees to the left or right, and least when both casters were oriented forward. The results show that drive direction error corresponds to the loading difference on the casters. The data indicates that loading differences may cause asymmetric drag on the casters, which in turn causes unbalanced torque load on the motors. This leads to a difference in motor speed and drive direction error.

Multiple Indicators, Multiple Causes Measurement Error Models

PubMed Central

Tekwe, Carmen D.; Carter, Randy L.; Cullings, Harry M.; Carroll, Raymond J.

2014-01-01

Multiple Indicators, Multiple Causes Models (MIMIC) are often employed by researchers studying the effects of an unobservable latent variable on a set of outcomes, when causes of the latent variable are observed. There are times however when the causes of the latent variable are not observed because measurements of the causal variable are contaminated by measurement error. The objectives of this paper are: (1) to develop a novel model by extending the classical linear MIMIC model to allow both Berkson and classical measurement errors, defining the MIMIC measurement error (MIMIC ME) model, (2) to develop likelihood based estimation methods for the MIMIC ME model, (3) to apply the newly defined MIMIC ME model to atomic bomb survivor data to study the impact of dyslipidemia and radiation dose on the physical manifestations of dyslipidemia. As a by-product of our work, we also obtain a data-driven estimate of the variance of the classical measurement error associated with an estimate of the amount of radiation dose received by atomic bomb survivors at the time of their exposure. PMID:24962535

Multiple indicators, multiple causes measurement error models

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

Tekwe, Carmen D.; Carter, Randy L.; Cullings, Harry M.

Multiple indicators, multiple causes (MIMIC) models are often employed by researchers studying the effects of an unobservable latent variable on a set of outcomes, when causes of the latent variable are observed. There are times, however, when the causes of the latent variable are not observed because measurements of the causal variable are contaminated by measurement error. The objectives of this study are as follows: (i) to develop a novel model by extending the classical linear MIMIC model to allow both Berkson and classical measurement errors, defining the MIMIC measurement error (MIMIC ME) model; (ii) to develop likelihood-based estimation methodsmore » for the MIMIC ME model; and (iii) to apply the newly defined MIMIC ME model to atomic bomb survivor data to study the impact of dyslipidemia and radiation dose on the physical manifestations of dyslipidemia. Finally, as a by-product of our work, we also obtain a data-driven estimate of the variance of the classical measurement error associated with an estimate of the amount of radiation dose received by atomic bomb survivors at the time of their exposure.« less

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol

PubMed Central

Westbrook, J I; Li, L; Raban, M Z; Baysari, M T; Prgomet, M; Georgiou, A; Kim, T; Lake, R; McCullagh, C; Dalla-Pozza, L; Karnon, J; O'Brien, T A; Ambler, G; Day, R; Cowell, C T; Gazarian, M; Worthington, R; Lehmann, C U; White, L; Barbaric, D; Gardo, A; Kelly, M; Kennedy, P

2016-01-01

Introduction Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes. Methods and analysis A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1 week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2). Ethics and dissemination The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations. Trial registration number Australian New Zealand Clinical Trials Registry (ANZCTR) 370325. PMID:27797997

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol.

PubMed

Westbrook, J I; Li, L; Raban, M Z; Baysari, M T; Mumford, V; Prgomet, M; Georgiou, A; Kim, T; Lake, R; McCullagh, C; Dalla-Pozza, L; Karnon, J; O'Brien, T A; Ambler, G; Day, R; Cowell, C T; Gazarian, M; Worthington, R; Lehmann, C U; White, L; Barbaric, D; Gardo, A; Kelly, M; Kennedy, P

2016-10-21

Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes. A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1 week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2). The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations. Australian New Zealand Clinical Trials Registry (ANZCTR) 370325. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Truncating mutations of HIBCH tend to cause severe phenotypes in cases with HIBCH deficiency: a case report and brief literature review.

PubMed

Tan, Hu; Chen, Xin; Lv, Weigang; Linpeng, Siyuan; Liang, Desheng; Wu, Lingqian

2018-04-27

3-hydroxyisobutryl-CoA hydrolase (HIBCH) deficiency is a rare inborn error of valine metabolism characterized by neurodegenerative symptoms and caused by recessive mutations in the HIBCH gene. In this study, utilizing whole exome sequencing, we identified two novel splicing mutations of HIBCH (c.304+3A>G; c.1010_1011+3delTGGTA) in a Chinese patient with characterized neurodegenerative features of HIBCH deficiency and bilateral syndactyly which was not reported in previous studies. Functional tests showed that both of these two mutations destroyed the normal splicing and reduced the expression of HIBCH protein. Through a literature review, a potential phenotype-genotype correlation was found that patients carrying truncating mutations tended to have more severe phenotypes compared with those with missense mutations. Our findings would widen the mutation spectrum of HIBCH causing HIBCH deficiency and the phenotypic spectrum of the disease. The potential genotype-phenotype correlation would be profitable for the treatment and management of patients with HIBCH deficiency.

Mean Bias in Seasonal Forecast Model and ENSO Prediction Error.

PubMed

Kim, Seon Tae; Jeong, Hye-In; Jin, Fei-Fei

2017-07-20

This study uses retrospective forecasts made using an APEC Climate Center seasonal forecast model to investigate the cause of errors in predicting the amplitude of El Niño Southern Oscillation (ENSO)-driven sea surface temperature variability. When utilizing Bjerknes coupled stability (BJ) index analysis, enhanced errors in ENSO amplitude with forecast lead times are found to be well represented by those in the growth rate estimated by the BJ index. ENSO amplitude forecast errors are most strongly associated with the errors in both the thermocline slope response and surface wind response to forcing over the tropical Pacific, leading to errors in thermocline feedback. This study concludes that upper ocean temperature bias in the equatorial Pacific, which becomes more intense with increasing lead times, is a possible cause of forecast errors in the thermocline feedback and thus in ENSO amplitude.

How should children with speech sound disorders be classified? A review and critical evaluation of current classification systems.

PubMed

Waring, R; Knight, R

2013-01-01

Children with speech sound disorders (SSD) form a heterogeneous group who differ in terms of the severity of their condition, underlying cause, speech errors, involvement of other aspects of the linguistic system and treatment response. To date there is no universal and agreed-upon classification system. Instead, a number of theoretically differing classification systems have been proposed based on either an aetiological (medical) approach, a descriptive-linguistic approach or a processing approach. To describe and review the supporting evidence, and to provide a critical evaluation of the current childhood SSD classification systems. Descriptions of the major specific approaches to classification are reviewed and research papers supporting the reliability and validity of the systems are evaluated. Three specific paediatric SSD classification systems; the aetiologic-based Speech Disorders Classification System, the descriptive-linguistic Differential Diagnosis system, and the processing-based Psycholinguistic Framework are identified as potentially useful in classifying children with SSD into homogeneous subgroups. The Differential Diagnosis system has a growing body of empirical support from clinical population studies, across language error pattern studies and treatment efficacy studies. The Speech Disorders Classification System is currently a research tool with eight proposed subgroups. The Psycholinguistic Framework is a potential bridge to linking cause and surface level speech errors. There is a need for a universally agreed-upon classification system that is useful to clinicians and researchers. The resulting classification system needs to be robust, reliable and valid. A universal classification system would allow for improved tailoring of treatments to subgroups of SSD which may, in turn, lead to improved treatment efficacy. © 2012 Royal College of Speech and Language Therapists.

Enhancements in healthcare information technology systems: customizing vendor-supplied clinical decision support for a high-risk patient population.

PubMed

Tiwari, Ruchi; Tsapepas, Demetra S; Powell, Jaclyn T; Martin, Spencer T

2013-01-01

Healthcare organizations continue to adopt information technologies with clinical decision support (CDS) to prevent potential medication-related adverse drug events. End-users who are unfamiliar with certain high-risk patient populations are at an increased risk of unknowingly causing medication errors. The following case describes a heart transplant recipient exposed to supra-therapeutic concentrations of tacrolimus during co-administration of ritonavir as a result of vendor supplied CDS tools that omitted an interaction alert. After review of 4692 potential tacrolimus-based DDIs between 329 different drug pairs supplied by vendor CDS, the severity of 20 DDIs were downgraded and the severity of 62 were upgraded. The need for institution-specific customization of vendor-provided CDS is paramount to ensure avoidance of medication errors. Individualized care will become more important as patient populations and institutions become more specialized. In the future, vendors providing integrated CDS tools must be proactive in developing institution-specific and easily customizable CDS tools.

Enhancements in healthcare information technology systems: customizing vendor-supplied clinical decision support for a high-risk patient population

PubMed Central

Tiwari, Ruchi; Tsapepas, Demetra S; Powell, Jaclyn T

2013-01-01

Healthcare organizations continue to adopt information technologies with clinical decision support (CDS) to prevent potential medication-related adverse drug events. End-users who are unfamiliar with certain high-risk patient populations are at an increased risk of unknowingly causing medication errors. The following case describes a heart transplant recipient exposed to supra-therapeutic concentrations of tacrolimus during co-administration of ritonavir as a result of vendor supplied CDS tools that omitted an interaction alert. After review of 4692 potential tacrolimus-based DDIs between 329 different drug pairs supplied by vendor CDS, the severity of 20 DDIs were downgraded and the severity of 62 were upgraded. The need for institution-specific customization of vendor-provided CDS is paramount to ensure avoidance of medication errors. Individualized care will become more important as patient populations and institutions become more specialized. In the future, vendors providing integrated CDS tools must be proactive in developing institution-specific and easily customizable CDS tools. PMID:22813760

Visuo-Vestibular Interactions

NASA Technical Reports Server (NTRS)

1997-01-01

Session TA3 includes short reports covering: (1) Vestibulo-Oculomotor Interaction in Long-Term Microgravity; (2) Effects of Weightlessness on the Spatial Orientation of Visually Induced Eye Movements; (3) Adaptive Modification of the Three-Dimensional Vestibulo-Ocular Reflex during Prolonged Microgravity; (4) The Dynamic Change of Brain Potential Related to Selective Attention to Visual Signals from Left and Right Visual Fields; (5) Locomotor Errors Caused by Vestibular Suppression; and (6) A Novel, Image-Based Technique for Three-Dimensional Eye Measurement.

An IMU-Aided Body-Shadowing Error Compensation Method for Indoor Bluetooth Positioning

PubMed Central

Deng, Zhongliang

2018-01-01

Research on indoor positioning technologies has recently become a hotspot because of the huge social and economic potential of indoor location-based services (ILBS). Wireless positioning signals have a considerable attenuation in received signal strength (RSS) when transmitting through human bodies, which would cause significant ranging and positioning errors in RSS-based systems. This paper mainly focuses on the body-shadowing impairment of RSS-based ranging and positioning, and derives a mathematical expression of the relation between the body-shadowing effect and the positioning error. In addition, an inertial measurement unit-aided (IMU-aided) body-shadowing detection strategy is designed, and an error compensation model is established to mitigate the effect of body-shadowing. A Bluetooth positioning algorithm with body-shadowing error compensation (BP-BEC) is then proposed to improve both the positioning accuracy and the robustness in indoor body-shadowing environments. Experiments are conducted in two indoor test beds, and the performance of both the BP-BEC algorithm and the algorithms without body-shadowing error compensation (named no-BEC) is evaluated. The results show that the BP-BEC outperforms the no-BEC by about 60.1% and 73.6% in terms of positioning accuracy and robustness, respectively. Moreover, the execution time of the BP-BEC algorithm is also evaluated, and results show that the convergence speed of the proposed algorithm has an insignificant effect on real-time localization. PMID:29361718

An IMU-Aided Body-Shadowing Error Compensation Method for Indoor Bluetooth Positioning.

PubMed

Deng, Zhongliang; Fu, Xiao; Wang, Hanhua

2018-01-20

Research on indoor positioning technologies has recently become a hotspot because of the huge social and economic potential of indoor location-based services (ILBS). Wireless positioning signals have a considerable attenuation in received signal strength (RSS) when transmitting through human bodies, which would cause significant ranging and positioning errors in RSS-based systems. This paper mainly focuses on the body-shadowing impairment of RSS-based ranging and positioning, and derives a mathematical expression of the relation between the body-shadowing effect and the positioning error. In addition, an inertial measurement unit-aided (IMU-aided) body-shadowing detection strategy is designed, and an error compensation model is established to mitigate the effect of body-shadowing. A Bluetooth positioning algorithm with body-shadowing error compensation (BP-BEC) is then proposed to improve both the positioning accuracy and the robustness in indoor body-shadowing environments. Experiments are conducted in two indoor test beds, and the performance of both the BP-BEC algorithm and the algorithms without body-shadowing error compensation (named no-BEC) is evaluated. The results show that the BP-BEC outperforms the no-BEC by about 60.1% and 73.6% in terms of positioning accuracy and robustness, respectively. Moreover, the execution time of the BP-BEC algorithm is also evaluated, and results show that the convergence speed of the proposed algorithm has an insignificant effect on real-time localization.

The Relationship Between Work Commitment, Dynamic, and Medication Error.

PubMed

Rezaiamin, Abdoolkarim; Pazokian, Marzieh; Zagheri Tafreshi, Mansoureh; Nasiri, Malihe

2017-05-01

Incidence of medication errors in intensive care unit (ICU) can cause irreparable damage for ICU patients. Therefore, it seems necessary to find the causes of medication errors in this section. Work commitment and dynamic might affect the incidence of medication errors in ICU. To assess the mentioned hypothesis, we performed a descriptive-analytical study which was carried out on 117 nurses working in ICU of educational hospitals in Tehran. Minick et al., Salyer et al., and Wakefield et al. scales were used for data gathering on work commitment, dynamic, and medication errors, respectively. Findings of the current study revealed that high work commitment in ICU nurses caused low number of medication errors, including intravenous and nonintravenous. We controlled the effects of confounding variables in detection of this relationship. In contrast, no significant association was found between work dynamic and different types of medication errors. Although the study did not observe any relationship between the dynamics and rate of medication errors, the training of nurses or nursing students to create a dynamic environment in hospitals can increase their interest in the profession and increase job satisfaction in them. Also they must have enough ability in work dynamic so that they don't confused and distracted result in frequent changes of orders, care plans, and procedures.

Directional control-response compatibility relationships assessed by physical simulation of an underground bolting machine.

PubMed

Steiner, Lisa; Burgess-Limerick, Robin; Porter, William

2014-03-01

The authors examine the pattern of direction errors made during the manipulation of a physical simulation of an underground coal mine bolting machine to assess the directional control-response compatibility relationships associated with the device and to compare these results to data obtained from a virtual simulation of a generic device. Directional errors during the manual control of underground coal roof bolting equipment are associated with serious injuries. Directional control-response relationships have previously been examined using a virtual simulation of a generic device; however, the applicability of these results to a specific physical device may be questioned. Forty-eight participants randomly assigned to different directional control-response relationships manipulated horizontal or vertical control levers to move a simulated bolter arm in three directions (elevation, slew, and sump) as well as to cause a light to become illuminated and raise or lower a stabilizing jack. Directional errors were recorded during the completion of 240 trials by each participant Directional error rates are increased when the control and response are in opposite directions or if the direction of the control and response are perpendicular.The pattern of direction error rates was consistent with experiments obtained from a generic device in a virtual environment. Error rates are increased by incompatible directional control-response relationships. Ensuring that the design of equipment controls maintains compatible directional control-response relationships has potential to reduce the errors made in high-risk situations, such as underground coal mining.

Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department.

PubMed

Sethuraman, Usha; Kannikeswaran, Nirupama; Murray, Kyle P; Zidan, Marwan A; Chamberlain, James M

2015-06-01

Prescription errors occur frequently in pediatric emergency departments (PEDs).The effect of computerized physician order entry (CPOE) with electronic medication alert system (EMAS) on these is unknown. The objective was to compare prescription errors rates before and after introduction of CPOE with EMAS in a PED. The hypothesis was that CPOE with EMAS would significantly reduce the rate and severity of prescription errors in the PED. A prospective comparison of a sample of outpatient, medication prescriptions 5 months before and after CPOE with EMAS implementation (7,268 before and 7,292 after) was performed. Error types and rates, alert types and significance, and physician response were noted. Medication errors were deemed significant if there was a potential to cause life-threatening injury, failure of therapy, or an adverse drug effect. There was a significant reduction in the errors per 100 prescriptions (10.4 before vs. 7.3 after; absolute risk reduction = 3.1, 95% confidence interval [CI] = 2.2 to 4.0). Drug dosing error rates decreased from 8 to 5.4 per 100 (absolute risk reduction = 2.6, 95% CI = 1.8 to 3.4). Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. The sensitivity of CPOE with EMAS in identifying errors in prescriptions was 45.1% (95% CI = 40.8% to 49.6%), and the specificity was 57% (95% CI = 55.6% to 58.5%). Prescribers modified 20% of the dosing alerts, resulting in the error not reaching the patient. Conversely, 11% of true dosing alerts for medication errors were overridden by the prescribers: 88 (11.3%) resulted in medication errors, and 684 (88.6%) were false-positive alerts. A CPOE with EMAS was associated with a decrease in overall prescription errors in our PED. Further system refinements are required to reduce the high false-positive alert rates. © 2015 by the Society for Academic Emergency Medicine.

Prediction of transmission distortion for wireless video communication: analysis.

PubMed

Chen, Zhifeng; Wu, Dapeng

2012-03-01

Transmitting video over wireless is a challenging problem since video may be seriously distorted due to packet errors caused by wireless channels. The capability of predicting transmission distortion (i.e., video distortion caused by packet errors) can assist in designing video encoding and transmission schemes that achieve maximum video quality or minimum end-to-end video distortion. This paper is aimed at deriving formulas for predicting transmission distortion. The contribution of this paper is twofold. First, we identify the governing law that describes how the transmission distortion process evolves over time and analytically derive the transmission distortion formula as a closed-form function of video frame statistics, channel error statistics, and system parameters. Second, we identify, for the first time, two important properties of transmission distortion. The first property is that the clipping noise, which is produced by nonlinear clipping, causes decay of propagated error. The second property is that the correlation between motion-vector concealment error and propagated error is negative and has dominant impact on transmission distortion, compared with other correlations. Due to these two properties and elegant error/distortion decomposition, our formula provides not only more accurate prediction but also lower complexity than the existing methods.

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

PubMed Central

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

2008-01-01

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

A system dynamic simulation model for managing the human error in power tools industries

NASA Astrophysics Data System (ADS)

Jamil, Jastini Mohd; Shaharanee, Izwan Nizal Mohd

2017-10-01

In the era of modern and competitive life of today, every organization will face the situations in which the work does not proceed as planned when there is problems occur in which it had to be delay. However, human error is often cited as the culprit. The error that made by the employees would cause them have to spend additional time to identify and check for the error which in turn could affect the normal operations of the company as well as the company's reputation. Employee is a key element of the organization in running all of the activities of organization. Hence, work performance of the employees is a crucial factor in organizational success. The purpose of this study is to identify the factors that cause the increasing errors make by employees in the organization by using system dynamics approach. The broadly defined targets in this study are employees in the Regional Material Field team from purchasing department in power tools industries. Questionnaires were distributed to the respondents to obtain their perceptions on the root cause of errors make by employees in the company. The system dynamics model was developed to simulate the factor of the increasing errors make by employees and its impact. The findings of this study showed that the increasing of error make by employees was generally caused by the factors of workload, work capacity, job stress, motivation and performance of employees. However, this problem could be solve by increased the number of employees in the organization.

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

NASA Technical Reports Server (NTRS)

Choi, Gwan Seung

1990-01-01

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

History, Epidemic Evolution, and Model Burn-In for a Network of Annual Invasion: Soybean Rust.

PubMed

Sanatkar, M R; Scoglio, C; Natarajan, B; Isard, S A; Garrett, K A

2015-07-01

Ecological history may be an important driver of epidemics and disease emergence. We evaluated the role of history and two related concepts, the evolution of epidemics and the burn-in period required for fitting a model to epidemic observations, for the U.S. soybean rust epidemic (caused by Phakopsora pachyrhizi). This disease allows evaluation of replicate epidemics because the pathogen reinvades the United States each year. We used a new maximum likelihood estimation approach for fitting the network model based on observed U.S. epidemics. We evaluated the model burn-in period by comparing model fit based on each combination of other years of observation. When the miss error rates were weighted by 0.9 and false alarm error rates by 0.1, the mean error rate did decline, for most years, as more years were used to construct models. Models based on observations in years closer in time to the season being estimated gave lower miss error rates for later epidemic years. The weighted mean error rate was lower in backcasting than in forecasting, reflecting how the epidemic had evolved. Ongoing epidemic evolution, and potential model failure, can occur because of changes in climate, host resistance and spatial patterns, or pathogen evolution.

Müller glia-derived PRSS56 is required to sustain ocular axial growth and prevent refractive error.

PubMed

Paylakhi, Seyyedhassan; Labelle-Dumais, Cassandre; Tolman, Nicholas G; Sellarole, Michael A; Seymens, Yusef; Saunders, Joseph; Lakosha, Hesham; deVries, Wilhelmine N; Orr, Andrew C; Topilko, Piotr; John, Simon Wm; Nair, K Saidas

2018-03-01

A mismatch between optical power and ocular axial length results in refractive errors. Uncorrected refractive errors constitute the most common cause of vision loss and second leading cause of blindness worldwide. Although the retina is known to play a critical role in regulating ocular growth and refractive development, the precise factors and mechanisms involved are poorly defined. We have previously identified a role for the secreted serine protease PRSS56 in ocular size determination and PRSS56 variants have been implicated in the etiology of both hyperopia and myopia, highlighting its importance in refractive development. Here, we use a combination of genetic mouse models to demonstrate that Prss56 mutations leading to reduced ocular size and hyperopia act via a loss of function mechanism. Using a conditional gene targeting strategy, we show that PRSS56 derived from Müller glia contributes to ocular growth, implicating a new retinal cell type in ocular size determination. Importantly, we demonstrate that persistent activity of PRSS56 is required during distinct developmental stages spanning the pre- and post-eye opening periods to ensure optimal ocular growth. Thus, our mouse data provide evidence for the existence of a molecule contributing to both the prenatal and postnatal stages of human ocular growth. Finally, we demonstrate that genetic inactivation of Prss56 rescues axial elongation in a mouse model of myopia caused by a null mutation in Egr1. Overall, our findings identify PRSS56 as a potential therapeutic target for modulating ocular growth aimed at preventing or slowing down myopia, which is reaching epidemic proportions.

Müller glia-derived PRSS56 is required to sustain ocular axial growth and prevent refractive error

PubMed Central

Tolman, Nicholas G; Sellarole, Michael A.; Saunders, Joseph; Lakosha, Hesham; Topilko, Piotr; John, Simon WM.

2018-01-01

A mismatch between optical power and ocular axial length results in refractive errors. Uncorrected refractive errors constitute the most common cause of vision loss and second leading cause of blindness worldwide. Although the retina is known to play a critical role in regulating ocular growth and refractive development, the precise factors and mechanisms involved are poorly defined. We have previously identified a role for the secreted serine protease PRSS56 in ocular size determination and PRSS56 variants have been implicated in the etiology of both hyperopia and myopia, highlighting its importance in refractive development. Here, we use a combination of genetic mouse models to demonstrate that Prss56 mutations leading to reduced ocular size and hyperopia act via a loss of function mechanism. Using a conditional gene targeting strategy, we show that PRSS56 derived from Müller glia contributes to ocular growth, implicating a new retinal cell type in ocular size determination. Importantly, we demonstrate that persistent activity of PRSS56 is required during distinct developmental stages spanning the pre- and post-eye opening periods to ensure optimal ocular growth. Thus, our mouse data provide evidence for the existence of a molecule contributing to both the prenatal and postnatal stages of human ocular growth. Finally, we demonstrate that genetic inactivation of Prss56 rescues axial elongation in a mouse model of myopia caused by a null mutation in Egr1. Overall, our findings identify PRSS56 as a potential therapeutic target for modulating ocular growth aimed at preventing or slowing down myopia, which is reaching epidemic proportions. PMID:29529029

Effect of asymmetrical transfer coefficients of a non-polarizing beam splitter on the nonlinear error of the polarization interferometer

NASA Astrophysics Data System (ADS)

Zhao, Chen-Guang; Tan, Jiu-Bin; Liu, Tao

2010-09-01

The mechanism of a non-polarizing beam splitter (NPBS) with asymmetrical transfer coefficients causing the rotation of polarization direction is explained in principle, and the measurement nonlinear error caused by NPBS is analyzed based on Jones matrix theory. Theoretical calculations show that the nonlinear error changes periodically, and the error period and peak values increase with the deviation between transmissivities of p-polarization and s-polarization states. When the transmissivity of p-polarization is 53% and that of s-polarization is 48%, the maximum error reaches 2.7 nm. The imperfection of NPBS is one of the main error sources in simultaneous phase-shifting polarization interferometer, and its influence can not be neglected in the nanoscale ultra-precision measurement.

Transient Faults in Computer Systems

NASA Technical Reports Server (NTRS)

Masson, Gerald M.

1993-01-01

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

Transition year labeling error characterization study. [Kansas, Minnesota, Montana, North Dakota, South Dakota, and Oklahoma

NASA Technical Reports Server (NTRS)

Clinton, N. J. (Principal Investigator)

1980-01-01

Labeling errors made in the large area crop inventory experiment transition year estimates by Earth Observation Division image analysts are identified and quantified. The analysis was made from a subset of blind sites in six U.S. Great Plains states (Oklahoma, Kansas, Montana, Minnesota, North and South Dakota). The image interpretation basically was well done, resulting in a total omission error rate of 24 percent and a commission error rate of 4 percent. The largest amount of error was caused by factors beyond the control of the analysts who were following the interpretation procedures. The odd signatures, the largest error cause group, occurred mostly in areas of moisture abnormality. Multicrop labeling was tabulated showing the distribution of labeling for all crops.

Gravity field recovery in the framework of a Geodesy and Time Reference in Space (GETRIS)

NASA Astrophysics Data System (ADS)

Hauk, Markus; Schlicht, Anja; Pail, Roland; Murböck, Michael

2017-04-01

The study ;Geodesy and Time Reference in Space; (GETRIS), funded by European Space Agency (ESA), evaluates the potential and opportunities coming along with a global space-borne infrastructure for data transfer, clock synchronization and ranging. Gravity field recovery could be one of the first beneficiary applications of such an infrastructure. This paper analyzes and evaluates the two-way high-low satellite-to-satellite-tracking as a novel method and as a long-term perspective for the determination of the Earth's gravitational field, using it as a synergy of one-way high-low combined with low-low satellite-to-satellite-tracking, in order to generate adequate de-aliasing products. First planned as a constellation of geostationary satellites, it turned out, that an integration of European Union Global Navigation Satellite System (Galileo) satellites (equipped with inter-Galileo links) into a Geostationary Earth Orbit (GEO) constellation would extend the capability of such a mission constellation remarkably. We report about simulations of different Galileo and Low Earth Orbiter (LEO) satellite constellations, computed using time variable geophysical background models, to determine temporal changes in the Earth's gravitational field. Our work aims at an error analysis of this new satellite/instrument scenario by investigating the impact of different error sources. Compared to a low-low satellite-to-satellite-tracking mission, results show reduced temporal aliasing errors due to a more isotropic error behavior caused by an improved observation geometry, predominantly in near-radial direction within the inter-satellite-links, as well as the potential of an improved gravity recovery with higher spatial and temporal resolution. The major error contributors of temporal gravity retrieval are aliasing errors due to undersampling of high frequency signals (mainly atmosphere, ocean and ocean tides). In this context, we investigate adequate methods to reduce these errors. We vary the number of Galileo and LEO satellites and show reduced errors in the temporal gravity field solutions for this enhanced inter-satellite-links. Based on the GETRIS infrastructure, the multiplicity of satellites enables co-estimating short-period long-wavelength gravity field signals, indicating it as powerful method for non-tidal aliasing reduction.

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

PubMed

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

2010-01-01

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

Directly patching high-level exchange-correlation potential based on fully determined optimized effective potentials

NASA Astrophysics Data System (ADS)

Huang, Chen; Chi, Yu-Chieh

2017-12-01

The key element in Kohn-Sham (KS) density functional theory is the exchange-correlation (XC) potential. We recently proposed the exchange-correlation potential patching (XCPP) method with the aim of directly constructing high-level XC potential in a large system by patching the locally computed, high-level XC potentials throughout the system. In this work, we investigate the patching of the exact exchange (EXX) and the random phase approximation (RPA) correlation potentials. A major challenge of XCPP is that a cluster's XC potential, obtained by solving the optimized effective potential equation, is only determined up to an unknown constant. Without fully determining the clusters' XC potentials, the patched system's XC potential is "uneven" in the real space and may cause non-physical results. Here, we developed a simple method to determine this unknown constant. The performance of XCPP-RPA is investigated on three one-dimensional systems: H20, H10Li8, and the stretching of the H19-H bond. We investigated two definitions of EXX: (i) the definition based on the adiabatic connection and fluctuation dissipation theorem (ACFDT) and (ii) the Hartree-Fock (HF) definition. With ACFDT-type EXX, effective error cancellations were observed between the patched EXX and the patched RPA correlation potentials. Such error cancellations were absent for the HF-type EXX, which was attributed to the fact that for systems with fractional occupation numbers, the integral of the HF-type EXX hole is not -1. The KS spectra and band gaps from XCPP agree reasonably well with the benchmarks as we make the clusters large.

Identification errors in the blood transfusion laboratory: a still relevant issue for patient safety.

PubMed

Lippi, Giuseppe; Plebani, Mario

2011-04-01

Remarkable technological advances and increased awareness have both contributed to decrease substantially the uncertainty of the analytical phase, so that the manually intensive preanalytical activities currently represent the leading sources of errors in laboratory and transfusion medicine. Among preanalytical errors, misidentification and mistransfusion are still regarded as a considerable problem, posing serious risks for patient health and carrying huge expenses for the healthcare system. As such, a reliable policy of risk management should be readily implemented, developing through a multifaceted approach to prevent or limit the adverse outcomes related to transfusion reactions from blood incompatibility. This strategy encompasses root cause analysis, compliance with accreditation requirements, strict adherence to standard operating procedures, guidelines and recommendations for specimen collection, use of positive identification devices, rejection of potentially misidentified specimens, informatics data entry, query host communication, automated systems for patient identification and sample labeling and an adequate and safe environment. Copyright © 2011 Elsevier Ltd. All rights reserved.

Development of a Precise Polarization Modulator for UV Spectropolarimetry

NASA Astrophysics Data System (ADS)

Ishikawa, S.; Shimizu, T.; Kano, R.; Bando, T.; Ishikawa, R.; Giono, G.; Tsuneta, S.; Nakayama, S.; Tajima, T.

2015-10-01

We developed a polarization modulation unit (PMU) to rotate a waveplate continuously in order to observe solar magnetic fields by spectropolarimetry. The non-uniformity of the PMU rotation may cause errors in the measurement of the degree of linear polarization (scale error) and its angle (crosstalk between Stokes-Q and -U), although it does not cause an artificial linear polarization signal (spurious polarization). We rotated a waveplate with the PMU to obtain a polarization modulation curve and estimated the scale error and crosstalk caused by the rotation non-uniformity. The estimated scale error and crosstalk were {<} 0.01 % for both. This PMU will be used as a waveplate motor for the Chromospheric Lyman-Alpha SpectroPolarimeter (CLASP) rocket experiment. We confirm that the PMU performs and functions sufficiently well for CLASP.

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

PubMed

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

2015-02-01

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

Human factors engineering and design validation for the redesigned follitropin alfa pen injection device.

PubMed

Mahony, Mary C; Patterson, Patricia; Hayward, Brooke; North, Robert; Green, Dawne

2015-05-01

To demonstrate, using human factors engineering (HFE), that a redesigned, pre-filled, ready-to-use, pre-asembled follitropin alfa pen can be used to administer prescribed follitropin alfa doses safely and accurately. A failure modes and effects analysis identified hazards and harms potentially caused by use errors; risk-control measures were implemented to ensure acceptable device use risk management. Participants were women with infertility, their significant others, and fertility nurse (FN) professionals. Preliminary testing included 'Instructions for Use' (IFU) and pre-validation studies. Validation studies used simulated injections in a representative use environment; participants received prior training on pen use. User performance in preliminary testing led to IFU revisions and a change to outer needle cap design to mitigate needle stick potential. In the first validation study (49 users, 343 simulated injections), in the FN group, one observed critical use error resulted in a device design modification and another in an IFU change. A second validation study tested the mitigation strategies; previously reported use errors were not repeated. Through an iterative process involving a series of studies, modifications were made to the pen design and IFU. Simulated-use testing demonstrated that the redesigned pen can be used to administer follitropin alfa effectively and safely.

The Significance of the Record Length in Flood Frequency Analysis

NASA Astrophysics Data System (ADS)

Senarath, S. U.

2013-12-01

Of all of the potential natural hazards, flood is the most costly in many regions of the world. For example, floods cause over a third of Europe's average annual catastrophe losses and affect about two thirds of the people impacted by natural catastrophes. Increased attention is being paid to determining flow estimates associated with pre-specified return periods so that flood-prone areas can be adequately protected against floods of particular magnitudes or return periods. Flood frequency analysis, which is conducted by using an appropriate probability density function that fits the observed annual maximum flow data, is frequently used for obtaining these flow estimates. Consequently, flood frequency analysis plays an integral role in determining the flood risk in flood prone watersheds. A long annual maximum flow record is vital for obtaining accurate estimates of discharges associated with high return period flows. However, in many areas of the world, flood frequency analysis is conducted with limited flow data or short annual maximum flow records. These inevitably lead to flow estimates that are subject to error. This is especially the case with high return period flow estimates. In this study, several statistical techniques are used to identify errors caused by short annual maximum flow records. The flow estimates used in the error analysis are obtained by fitting a log-Pearson III distribution to the flood time-series. These errors can then be used to better evaluate the return period flows in data limited streams. The study findings, therefore, have important implications for hydrologists, water resources engineers and floodplain managers.

Identification of driver errors : overview and recommendations

DOT National Transportation Integrated Search

2002-08-01

Driver error is cited as a contributing factor in most automobile crashes, and although estimates vary by source, driver error is cited as the principal cause of from 45 to 75 percent of crashes. However, the specific errors that lead to crashes, and...

Low Probability Tail Event Analysis and Mitigation in BPA Control Area: Task One Report

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

Lu, Shuai; Makarov, Yuri V.

This is a report for task one of the tail event analysis project for BPA. Tail event refers to the situation in a power system when unfavorable forecast errors of load and wind are superposed onto fast load and wind ramps, or non-wind generators falling short of scheduled output, the imbalance between generation and load becomes very significant. This type of events occurs infrequently and appears on the tails of the distribution of system power imbalance; therefore, is referred to as tail events. This report analyzes what happened during the Electric Reliability Council of Texas (ERCOT) reliability event on Februarymore » 26, 2008, which was widely reported because of the involvement of wind generation. The objective is to identify sources of the problem, solutions to it and potential improvements that can be made to the system. Lessons learned from the analysis include the following: (1) Large mismatch between generation and load can be caused by load forecast error, wind forecast error and generation scheduling control error on traditional generators, or a combination of all of the above; (2) The capability of system balancing resources should be evaluated both in capacity (MW) and in ramp rate (MW/min), and be procured accordingly to meet both requirements. The resources need to be able to cover a range corresponding to the variability of load and wind in the system, additional to other uncertainties; (3) Unexpected ramps caused by load and wind can both become the cause leading to serious issues; (4) A look-ahead tool evaluating system balancing requirement during real-time operations and comparing that with available system resources should be very helpful to system operators in predicting the forthcoming of similar events and planning ahead; and (5) Demand response (only load reduction in ERCOT event) can effectively reduce load-generation mismatch and terminate frequency deviation in an emergency situation.« less

Underlying Cause(s) of Letter Perseveration Errors

PubMed Central

Fischer-Baum, Simon; Rapp, Brenda

2011-01-01

Perseverations, the inappropriate intrusion of elements from a previous response into a current response, are commonly observed in individuals with acquired deficits. This study specifically investigates the contribution of failure-to activate and failure-to-inhibit deficit(s) in the generation of letter perseveration errors in acquired dysgraphia. We provide evidence from the performance 12 dysgraphic individuals indicating that a failure to activate graphemes for a target word gives rise to letter perseveration errors. In addition, we also provide evidence that, in some individuals, a failure-to-inhibit deficit may also contribute to the production of perseveration errors. PMID:22178232

Measuring quality in anatomic pathology.

PubMed

Raab, Stephen S; Grzybicki, Dana Marie

2008-06-01

This article focuses mainly on diagnostic accuracy in measuring quality in anatomic pathology, noting that measuring any quality metric is complex and demanding. The authors discuss standardization and its variability within and across areas of care delivery and efforts involving defining and measuring error to achieve pathology quality and patient safety. They propose that data linking error to patient outcome are critical for developing quality improvement initiatives targeting errors that cause patient harm in addition to using methods of root cause analysis, beyond those traditionally used in cytologic-histologic correlation, to assist in the development of error reduction and quality improvement plans.

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings

PubMed Central

Beer, Idal; Hoppe-Tichy, Torsten; Trbovich, Patricia

2017-01-01

Objective To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings. Methods Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method. Results Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes. Conclusions The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors. PMID:29288174

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

NASA Astrophysics Data System (ADS)

Duan, Wansuo; Zhao, Peng

2017-04-01

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

Influence of ultraviolet irradiation on data retention characteristics in resistive random access memory

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

Kimura, K.; Ohmi, K.; Tottori University Electronic Display Research Center, 101 Minami4-chome, Koyama-cho, Tottori-shi, Tottori 680-8551

With increasing density of memory devices, the issue of generating soft errors by cosmic rays is becoming more and more serious. Therefore, the irradiation resistance of resistance random access memory (ReRAM) to cosmic radiation has to be elucidated for practical use. In this paper, we investigated the data retention characteristics of ReRAM against ultraviolet irradiation with a Pt/NiO/ITO structure. Soft errors were confirmed to be caused by ultraviolet irradiation in both low- and high-resistance states. An analysis of the wavelength dependence of light irradiation on data retention characteristics suggested that electronic excitation from the valence to the conduction band andmore » to the energy level generated due to the introduction of oxygen vacancies caused the errors. Based on a statistically estimated soft error rates, the errors were suggested to be caused by the cohesion and dispersion of oxygen vacancies owing to the generation of electron-hole pairs and valence changes by the ultraviolet irradiation.« less

Understanding overlay signatures using machine learning on non-lithography context information

NASA Astrophysics Data System (ADS)

Overcast, Marshall; Mellegaard, Corey; Daniel, David; Habets, Boris; Erley, Georg; Guhlemann, Steffen; Thrun, Xaver; Buhl, Stefan; Tottewitz, Steven

2018-03-01

Overlay errors between two layers can be caused by non-lithography processes. While these errors can be compensated by the run-to-run system, such process and tool signatures are not always stable. In order to monitor the impact of non-lithography context on overlay at regular intervals, a systematic approach is needed. Using various machine learning techniques, significant context parameters that relate to deviating overlay signatures are automatically identified. Once the most influential context parameters are found, a run-to-run simulation is performed to see how much improvement can be obtained. The resulting analysis shows good potential for reducing the influence of hidden context parameters on overlay performance. Non-lithographic contexts are significant contributors, and their automatic detection and classification will enable the overlay roadmap, given the corresponding control capabilities.

Progress in NEXT Ion Optics Modeling

NASA Technical Reports Server (NTRS)

Emhoff, Jerold W.; Boyd, Iain D.

2004-01-01

Results are presented from an ion optics simulation code applied to the NEXT ion thruster geometry. The error in the potential field solver of the code is characterized, and methods and requirements for reducing this error are given. Results from a study on electron backstreaming using the improved field solver are given and shown to compare much better to experimental results than previous studies. Results are also presented on a study of the beamlet behavior in the outer radial apertures of the NEXT thruster. The low beamlet currents in this region allow over-focusing of the beam, causing direct impingement of ions on the accelerator grid aperture wall. Different possibilities for reducing this direct impingement are analyzed, with the conclusion that, of the methods studied, decreasing the screen grid aperture diameter eliminates direct impingement most effectively.

Lateral velocity estimation bias due to beamforming delay errors (Conference Presentation)

NASA Astrophysics Data System (ADS)

Rodriguez-Molares, Alfonso; Fadnes, Solveig; Swillens, Abigail; Løvstakken, Lasse

2017-03-01

An artefact has recently been reported [1,2] in the estimation of the lateral blood velocity using speckle tracking. This artefact shows as a net velocity bias in presence of strong spatial velocity gradients such as those that occur at the edges of the filling jets in the heart. Even though this artifact has been found both in vitro and in simulated data, its causes are still undescribed. Here we demonstrate that a potential source of this artefact can be traced to smaller errors in the beamforming setup. By inserting a small offset in the beamforming delay, one can artificially create a net lateral movement in the speckle in areas of high velocity gradient. That offset does not have a strong impact in the image quality and can easily go undetected.

A vision-based system for fast and accurate laser scanning in robot-assisted phonomicrosurgery.

PubMed

Dagnino, Giulio; Mattos, Leonardo S; Caldwell, Darwin G

2015-02-01

Surgical quality in phonomicrosurgery can be improved by open-loop laser control (e.g., high-speed scanning capabilities) with a robust and accurate closed-loop visual servoing systems. A new vision-based system for laser scanning control during robot-assisted phonomicrosurgery was developed and tested. Laser scanning was accomplished with a dual control strategy, which adds a vision-based trajectory correction phase to a fast open-loop laser controller. The system is designed to eliminate open-loop aiming errors caused by system calibration limitations and by the unpredictable topology of real targets. Evaluation of the new system was performed using CO(2) laser cutting trials on artificial targets and ex-vivo tissue. This system produced accuracy values corresponding to pixel resolution even when smoke created by the laser-target interaction clutters the camera view. In realistic test scenarios, trajectory following RMS errors were reduced by almost 80 % with respect to open-loop system performances, reaching mean error values around 30 μ m and maximum observed errors in the order of 60 μ m. A new vision-based laser microsurgical control system was shown to be effective and promising with significant positive potential impact on the safety and quality of laser microsurgeries.

Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement.

PubMed

Lipira, Lauren E; Gallagher, Thomas H

2014-07-01

The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.

Heterodyne range imaging as an alternative to photogrammetry

NASA Astrophysics Data System (ADS)

Dorrington, Adrian; Cree, Michael; Carnegie, Dale; Payne, Andrew; Conroy, Richard

2007-01-01

Solid-state full-field range imaging technology, capable of determining the distance to objects in a scene simultaneously for every pixel in an image, has recently achieved sub-millimeter distance measurement precision. With this level of precision, it is becoming practical to use this technology for high precision three-dimensional metrology applications. Compared to photogrammetry, range imaging has the advantages of requiring only one viewing angle, a relatively short measurement time, and simplistic fast data processing. In this paper we fist review the range imaging technology, then describe an experiment comparing both photogrammetric and range imaging measurements of a calibration block with attached retro-reflective targets. The results show that the range imaging approach exhibits errors of approximately 0.5 mm in-plane and almost 5 mm out-of-plane; however, these errors appear to be mostly systematic. We then proceed to examine the physical nature and characteristics of the image ranging technology and discuss the possible causes of these systematic errors. Also discussed is the potential for further system characterization and calibration to compensate for the range determination and other errors, which could possibly lead to three-dimensional measurement precision approaching that of photogrammetry.

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

Precise-spike-driven synaptic plasticity: learning hetero-association of spatiotemporal spike patterns.

PubMed

Yu, Qiang; Tang, Huajin; Tan, Kay Chen; Li, Haizhou

2013-01-01

A new learning rule (Precise-Spike-Driven (PSD) Synaptic Plasticity) is proposed for processing and memorizing spatiotemporal patterns. PSD is a supervised learning rule that is analytically derived from the traditional Widrow-Hoff rule and can be used to train neurons to associate an input spatiotemporal spike pattern with a desired spike train. Synaptic adaptation is driven by the error between the desired and the actual output spikes, with positive errors causing long-term potentiation and negative errors causing long-term depression. The amount of modification is proportional to an eligibility trace that is triggered by afferent spikes. The PSD rule is both computationally efficient and biologically plausible. The properties of this learning rule are investigated extensively through experimental simulations, including its learning performance, its generality to different neuron models, its robustness against noisy conditions, its memory capacity, and the effects of its learning parameters. Experimental results show that the PSD rule is capable of spatiotemporal pattern classification, and can even outperform a well studied benchmark algorithm with the proposed relative confidence criterion. The PSD rule is further validated on a practical example of an optical character recognition problem. The results again show that it can achieve a good recognition performance with a proper encoding. Finally, a detailed discussion is provided about the PSD rule and several related algorithms including tempotron, SPAN, Chronotron and ReSuMe.

Precise-Spike-Driven Synaptic Plasticity: Learning Hetero-Association of Spatiotemporal Spike Patterns

PubMed Central

Yu, Qiang; Tang, Huajin; Tan, Kay Chen; Li, Haizhou

2013-01-01

A new learning rule (Precise-Spike-Driven (PSD) Synaptic Plasticity) is proposed for processing and memorizing spatiotemporal patterns. PSD is a supervised learning rule that is analytically derived from the traditional Widrow-Hoff rule and can be used to train neurons to associate an input spatiotemporal spike pattern with a desired spike train. Synaptic adaptation is driven by the error between the desired and the actual output spikes, with positive errors causing long-term potentiation and negative errors causing long-term depression. The amount of modification is proportional to an eligibility trace that is triggered by afferent spikes. The PSD rule is both computationally efficient and biologically plausible. The properties of this learning rule are investigated extensively through experimental simulations, including its learning performance, its generality to different neuron models, its robustness against noisy conditions, its memory capacity, and the effects of its learning parameters. Experimental results show that the PSD rule is capable of spatiotemporal pattern classification, and can even outperform a well studied benchmark algorithm with the proposed relative confidence criterion. The PSD rule is further validated on a practical example of an optical character recognition problem. The results again show that it can achieve a good recognition performance with a proper encoding. Finally, a detailed discussion is provided about the PSD rule and several related algorithms including tempotron, SPAN, Chronotron and ReSuMe. PMID:24223789

Hyperspectral Analysis of Soil Total Nitrogen in Subsided Land Using the Local Correlation Maximization-Complementary Superiority (LCMCS) Method

PubMed Central

Lin, Lixin; Wang, Yunjia; Teng, Jiyao; Xi, Xiuxiu

2015-01-01

The measurement of soil total nitrogen (TN) by hyperspectral remote sensing provides an important tool for soil restoration programs in areas with subsided land caused by the extraction of natural resources. This study used the local correlation maximization-complementary superiority method (LCMCS) to establish TN prediction models by considering the relationship between spectral reflectance (measured by an ASD FieldSpec 3 spectroradiometer) and TN based on spectral reflectance curves of soil samples collected from subsided land which is determined by synthetic aperture radar interferometry (InSAR) technology. Based on the 1655 selected effective bands of the optimal spectrum (OSP) of the first derivate differential of reciprocal logarithm ([log{1/R}]′), (correlation coefficients, p < 0.01), the optimal model of LCMCS method was obtained to determine the final model, which produced lower prediction errors (root mean square error of validation [RMSEV] = 0.89, mean relative error of validation [MREV] = 5.93%) when compared with models built by the local correlation maximization (LCM), complementary superiority (CS) and partial least squares regression (PLS) methods. The predictive effect of LCMCS model was optional in Cangzhou, Renqiu and Fengfeng District. Results indicate that the LCMCS method has great potential to monitor TN in subsided lands caused by the extraction of natural resources including groundwater, oil and coal. PMID:26213935

Numerical simulation of a low-lying barrier island's morphological response to Hurricane Katrina

USGS Publications Warehouse

Lindemer, C.A.; Plant, N.G.; Puleo, J.A.; Thompson, D.M.; Wamsley, T.V.

2010-01-01

Tropical cyclones that enter or form in the Gulf of Mexico generate storm surge and large waves that impact low-lying coastlines along the Gulf Coast. The Chandeleur Islands, located 161. km east of New Orleans, Louisiana, have endured numerous hurricanes that have passed nearby. Hurricane Katrina (landfall near Waveland MS, 29 Aug 2005) caused dramatic changes to the island elevation and shape. In this paper the predictability of hurricane-induced barrier island erosion and accretion is evaluated using a coupled hydrodynamic and morphodynamic model known as XBeach. Pre- and post-storm island topography was surveyed with an airborne lidar system. Numerical simulations utilized realistic surge and wave conditions determined from larger-scale hydrodynamic models. Simulations included model sensitivity tests with varying grid size and temporal resolutions. Model-predicted bathymetry/topography and post-storm survey data both showed similar patterns of island erosion, such as increased dissection by channels. However, the model under predicted the magnitude of erosion. Potential causes for under prediction include (1) errors in the initial conditions (the initial bathymetry/topography was measured three years prior to Katrina), (2) errors in the forcing conditions (a result of our omission of storms prior to Katrina and/or errors in Katrina storm conditions), and/or (3) physical processes that were omitted from the model (e.g., inclusion of sediment variations and bio-physical processes). ?? 2010.

Cognitive aspect of diagnostic errors.

PubMed

Phua, Dong Haur; Tan, Nigel C K

2013-01-01

Diagnostic errors can result in tangible harm to patients. Despite our advances in medicine, the mental processes required to make a diagnosis exhibits shortcomings, causing diagnostic errors. Cognitive factors are found to be an important cause of diagnostic errors. With new understanding from psychology and social sciences, clinical medicine is now beginning to appreciate that our clinical reasoning can take the form of analytical reasoning or heuristics. Different factors like cognitive biases and affective influences can also impel unwary clinicians to make diagnostic errors. Various strategies have been proposed to reduce the effect of cognitive biases and affective influences when clinicians make diagnoses; however evidence for the efficacy of these methods is still sparse. This paper aims to introduce the reader to the cognitive aspect of diagnostic errors, in the hope that clinicians can use this knowledge to improve diagnostic accuracy and patient outcomes.

Patient safety awareness among Undergraduate Medical Students in Pakistani Medical School.

PubMed

Kamran, Rizwana; Bari, Attia; Khan, Rehan Ahmed; Al-Eraky, Mohamed

2018-01-01

To measure the level of awareness of patient safety among undergraduate medical students in Pakistani Medical School and to find the difference with respect to gender and prior experience with medical error. This cross-sectional study was conducted at the University of Lahore (UOL), Pakistan from January to March 2017, and comprised final year medical students. Data was collected using a questionnaire 'APSQ- III' on 7 point Likert scale. Eight questions were reverse coded. Survey was anonymous. SPSS package 20 was used for statistical analysis. Questionnaire was filled by 122 students, with 81% response rate. The best score 6.17 was given for the 'team functioning', followed by 6.04 for 'long working hours as a cause of medical error'. The domains regarding involvement of patient, confidence to report medical errors and role of training and learning on patient safety scored high in the agreed range of >5. Reverse coded questions about 'professional incompetence as an error cause' and 'disclosure of errors' showed negative perception. No significant differences of perceptions were found with respect to gender and prior experience with medical error (p= >0.05). Undergraduate medical students at UOL had a positive attitude towards patient safety. However, there were misconceptions about causes of medical errors and error disclosure among students and patient safety education needs to be incorporated in medical curriculum of Pakistan.

Liquid Junction and Membrane Potentials of the Squid Giant Axon

PubMed Central

Cole, Kenneth S.; Moore, John W.

1960-01-01

The potential differences across the squid giant axon membrane, as measured with a series of microcapillary electrodes filled with concentrations of KCl from 0.03 to 3.0 M or sea water, are consistent with a constant membrane potential and the liquid junction potentials calculated by the Henderson equation. The best value for the mobility of an organic univalent ion, such as isethionate, leads to a probably low, but not impossible, axoplasm specific resistance of 1.2 times sea water and to a liquid junction correction of 4 mv. for microelectrodes filled with 3 M KCl. The errors caused by the assumptions of proportional mixing, unity activity coefficients, and a negligible internal fixed charge cannot be estimated but the results suggest that the cumulative effect of them may not be serious. PMID:13811119

Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry.

PubMed

Oliven, A; Zalman, D; Shilankov, Y; Yeshurun, D; Odeh, M

2002-01-01

Computerized prescription of drugs is expected to reduce the number of many preventable drug ordering errors. In the present study we evaluated the usefullness of a computerized drug order entry (CDOE) system in reducing prescription errors. A department of internal medicine using a comprehensive CDOE, which included also patient-related drug-laboratory, drug-disease and drug-allergy on-line surveillance was compared to a similar department in which drug orders were handwritten. CDOE reduced prescription errors to 25-35%. The causes of errors remained similar, and most errors, on both departments, were associated with abnormal renal function and electrolyte balance. Residual errors remaining on the CDOE-using department were due to handwriting on the typed order, failure to feed patients' diseases, and system failures. The use of CDOE was associated with a significant reduction in mean hospital stay and in the number of changes performed in the prescription. The findings of this study both quantity the impact of comprehensive CDOE on prescription errors and delineate the causes for remaining errors.

Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation, and Response to Medical Errors.

PubMed

Dreisinger, Naomi; Zapolsky, Nathan

2017-02-01

The emergency department (ED) is an environment that is conducive to medical errors. The ED is a time-pressured environment where physicians aim to rapidly evaluate and treat patients. Quick thinking and problem-based solutions are often used to assist in evaluation and diagnosis. Error analysis leads to an understanding of the cause of a medical error and is important to prevent future errors. Research suggests mechanisms to prevent medical errors in the pediatric ED, but prevention is not always possible. Transparency about errors is necessary to assure a trusting doctor-patient relationship. Patients want to be informed about all errors, and apologies are hard. Apologizing for a significant medical error that may have caused a complication is even harder. Having a systematic way to go about apologizing makes the process easier, and helps assure that the right information is relayed to the patient and his or her family. This creates an environment of autonomy and shared decision making that is ultimately beneficial to all aspects of patient care.

Preventing medical errors by designing benign failures.

PubMed

Grout, John R

2003-07-01

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

Blood specimen labelling errors: Implications for nephrology nursing practice.

PubMed

Duteau, Jennifer

2014-01-01

Patient safety is the foundation of high-quality health care, as recognized both nationally and worldwide. Patient blood specimen identification is critical in ensuring the delivery of safe and appropriate care. The practice of nephrology nursing involves frequent patient blood specimen withdrawals to treat and monitor kidney disease. A critical review of the literature reveals that incorrect patient identification is one of the major causes of blood specimen labelling errors. Misidentified samples create a serious risk to patient safety leading to multiple specimen withdrawals, delay in diagnosis, misdiagnosis, incorrect treatment, transfusion reactions, increased length of stay and other negative patient outcomes. Barcode technology has been identified as a preferred method for positive patient identification leading to a definitive decrease in blood specimen labelling errors by as much as 83% (Askeland, et al., 2008). The use of a root cause analysis followed by an action plan is one approach to decreasing the occurrence of blood specimen labelling errors. This article will present a review of the evidence-based literature surrounding blood specimen labelling errors, followed by author recommendations for completing a root cause analysis and action plan. A failure modes and effects analysis (FMEA) will be presented as one method to determine root cause, followed by the Ottawa Model of Research Use (OMRU) as a framework for implementation of strategies to reduce blood specimen labelling errors.

On Statistical Modeling of Sequencing Noise in High Depth Data to Assess Tumor Evolution

NASA Astrophysics Data System (ADS)

Rabadan, Raul; Bhanot, Gyan; Marsilio, Sonia; Chiorazzi, Nicholas; Pasqualucci, Laura; Khiabanian, Hossein

2018-07-01

One cause of cancer mortality is tumor evolution to therapy-resistant disease. First line therapy often targets the dominant clone, and drug resistance can emerge from preexisting clones that gain fitness through therapy-induced natural selection. Such mutations may be identified using targeted sequencing assays by analysis of noise in high-depth data. Here, we develop a comprehensive, unbiased model for sequencing error background. We find that noise in sufficiently deep DNA sequencing data can be approximated by aggregating negative binomial distributions. Mutations with frequencies above noise may have prognostic value. We evaluate our model with simulated exponentially expanded populations as well as data from cell line and patient sample dilution experiments, demonstrating its utility in prognosticating tumor progression. Our results may have the potential to identify significant mutations that can cause recurrence. These results are relevant in the pretreatment clinical setting to determine appropriate therapy and prepare for potential recurrence pretreatment.

On Statistical Modeling of Sequencing Noise in High Depth Data to Assess Tumor Evolution

NASA Astrophysics Data System (ADS)

Rabadan, Raul; Bhanot, Gyan; Marsilio, Sonia; Chiorazzi, Nicholas; Pasqualucci, Laura; Khiabanian, Hossein

2017-12-01

One cause of cancer mortality is tumor evolution to therapy-resistant disease. First line therapy often targets the dominant clone, and drug resistance can emerge from preexisting clones that gain fitness through therapy-induced natural selection. Such mutations may be identified using targeted sequencing assays by analysis of noise in high-depth data. Here, we develop a comprehensive, unbiased model for sequencing error background. We find that noise in sufficiently deep DNA sequencing data can be approximated by aggregating negative binomial distributions. Mutations with frequencies above noise may have prognostic value. We evaluate our model with simulated exponentially expanded populations as well as data from cell line and patient sample dilution experiments, demonstrating its utility in prognosticating tumor progression. Our results may have the potential to identify significant mutations that can cause recurrence. These results are relevant in the pretreatment clinical setting to determine appropriate therapy and prepare for potential recurrence pretreatment.

Underlying Cause(s) of Letter Perseveration Errors

ERIC Educational Resources Information Center

Fischer-Baum, Simon; Rapp, Brenda

2012-01-01

Perseverations, the inappropriate intrusion of elements from a previous response into a current response, are commonly observed in individuals with acquired deficits. This study specifically investigates the contribution of failure-to activate and failure-to-inhibit deficit(s) in the generation of letter perseveration errors in acquired…

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

PubMed

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

2010-05-06

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

F-16 Class A mishaps in the U.S. Air Force, 1975-93.

PubMed

Knapp, C J; Johnson, R

1996-08-01

All USAF F-16 fighter Class A (major) aircraft mishaps from 1975-93 were analyzed, using records from the U.S. Air Force Safety Agency (AFSA). There were 190 Class A mishaps involving 204 F-16's and 217 aircrew during this 19-yr period. The overall Class A rate was 5.09 per 100,000 flight hours, more than double the overall USAF rate. The mishaps are categorized by year, month, time of day and model of aircraft in relation to mishap causes as determined and reported by AFSA. Formation position, phase of flight and primary cause of the mishap indicate that maneuvering, cruise and low-level phases account for the majority of the mishaps (71%), with air-to-air engagements associated with a higher proportion of pilot error (71%) than was air-to-ground (49%). Engine failure was the number one cause of mishaps (35%), and collision with the ground the next most frequent (24%). Pilot error was determined as causative in 55% of all the mishaps. Pilot error was often associated with other non-pilot related causes. Channelized attention, loss of situational awareness, and spatial disorientation accounted for approximately 30% of the total pilot error causes found. Pilot demographics, flight hour/sortie profiles, and aircrew injuries are also listed. Fatalities occurred in 27% of the mishaps, with 97% of those involving pilot errors.

Human Error In Complex Systems

NASA Technical Reports Server (NTRS)

Morris, Nancy M.; Rouse, William B.

1991-01-01

Report presents results of research aimed at understanding causes of human error in such complex systems as aircraft, nuclear powerplants, and chemical processing plants. Research considered both slips (errors of action) and mistakes (errors of intention), and influence of workload on them. Results indicated that: humans respond to conditions in which errors expected by attempting to reduce incidence of errors; and adaptation to conditions potent influence on human behavior in discretionary situations.

A large-area, spatially continuous assessment of land cover map error and its impact on downstream analyses.

PubMed

Estes, Lyndon; Chen, Peng; Debats, Stephanie; Evans, Tom; Ferreira, Stefanus; Kuemmerle, Tobias; Ragazzo, Gabrielle; Sheffield, Justin; Wolf, Adam; Wood, Eric; Caylor, Kelly

2018-01-01

Land cover maps increasingly underlie research into socioeconomic and environmental patterns and processes, including global change. It is known that map errors impact our understanding of these phenomena, but quantifying these impacts is difficult because many areas lack adequate reference data. We used a highly accurate, high-resolution map of South African cropland to assess (1) the magnitude of error in several current generation land cover maps, and (2) how these errors propagate in downstream studies. We first quantified pixel-wise errors in the cropland classes of four widely used land cover maps at resolutions ranging from 1 to 100 km, and then calculated errors in several representative "downstream" (map-based) analyses, including assessments of vegetative carbon stocks, evapotranspiration, crop production, and household food security. We also evaluated maps' spatial accuracy based on how precisely they could be used to locate specific landscape features. We found that cropland maps can have substantial biases and poor accuracy at all resolutions (e.g., at 1 km resolution, up to ∼45% underestimates of cropland (bias) and nearly 50% mean absolute error (MAE, describing accuracy); at 100 km, up to 15% underestimates and nearly 20% MAE). National-scale maps derived from higher-resolution imagery were most accurate, followed by multi-map fusion products. Constraining mapped values to match survey statistics may be effective at minimizing bias (provided the statistics are accurate). Errors in downstream analyses could be substantially amplified or muted, depending on the values ascribed to cropland-adjacent covers (e.g., with forest as adjacent cover, carbon map error was 200%-500% greater than in input cropland maps, but ∼40% less for sparse cover types). The average locational error was 6 km (600%). These findings provide deeper insight into the causes and potential consequences of land cover map error, and suggest several recommendations for land cover map users. © 2017 John Wiley & Sons Ltd.

Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study.

PubMed

Terkola, R; Czejka, M; Bérubé, J

2017-08-01

Medication errors are a significant cause of morbidity and mortality especially with antineoplastic drugs, owing to their narrow therapeutic index. Gravimetric workflow software systems have the potential to reduce volumetric errors during intravenous antineoplastic drug preparation which may occur when verification is reliant on visual inspection. Our aim was to detect medication errors with possible critical therapeutic impact as determined by the rate of prevented medication errors in chemotherapy compounding after implementation of gravimetric measurement. A large-scale, retrospective analysis of data was carried out, related to medication errors identified during preparation of antineoplastic drugs in 10 pharmacy services ("centres") in five European countries following the introduction of an intravenous workflow software gravimetric system. Errors were defined as errors in dose volumes outside tolerance levels, identified during weighing stages of preparation of chemotherapy solutions which would not otherwise have been detected by conventional visual inspection. The gravimetric system detected that 7.89% of the 759 060 doses of antineoplastic drugs prepared at participating centres between July 2011 and October 2015 had error levels outside the accepted tolerance range set by individual centres, and prevented these doses from reaching patients. The proportion of antineoplastic preparations with deviations >10% ranged from 0.49% to 5.04% across sites, with a mean of 2.25%. The proportion of preparations with deviations >20% ranged from 0.21% to 1.27% across sites, with a mean of 0.71%. There was considerable variation in error levels for different antineoplastic agents. Introduction of a gravimetric preparation system for antineoplastic agents detected and prevented dosing errors which would not have been recognized with traditional methods and could have resulted in toxicity or suboptimal therapeutic outcomes for patients undergoing anticancer treatment. © 2017 The Authors. Journal of Clinical Pharmacy and Therapeutics Published by John Wiley & Sons Ltd.

Increased instrument intelligence--can it reduce laboratory error?

PubMed

Jekelis, Albert W

2005-01-01

Recent literature has focused on the reduction of laboratory errors and the potential impact on patient management. This study assessed the intelligent, automated preanalytical process-control abilities in newer generation analyzers as compared with older analyzers and the impact on error reduction. Three generations of immuno-chemistry analyzers were challenged with pooled human serum samples for a 3-week period. One of the three analyzers had an intelligent process of fluidics checks, including bubble detection. Bubbles can cause erroneous results due to incomplete sample aspiration. This variable was chosen because it is the most easily controlled sample defect that can be introduced. Traditionally, lab technicians have had to visually inspect each sample for the presence of bubbles. This is time consuming and introduces the possibility of human error. Instruments with bubble detection may be able to eliminate the human factor and reduce errors associated with the presence of bubbles. Specific samples were vortexed daily to introduce a visible quantity of bubbles, then immediately placed in the daily run. Errors were defined as a reported result greater than three standard deviations below the mean and associated with incomplete sample aspiration of the analyte of the individual analyzer Three standard deviations represented the target limits of proficiency testing. The results of the assays were examined for accuracy and precision. Efficiency, measured as process throughput, was also measured to associate a cost factor and potential impact of the error detection on the overall process. The analyzer performance stratified according to their level of internal process control The older analyzers without bubble detection reported 23 erred results. The newest analyzer with bubble detection reported one specimen incorrectly. The precision and accuracy of the nonvortexed specimens were excellent and acceptable for all three analyzers. No errors were found in the nonvortexed specimens. There were no significant differences in overall process time for any of the analyzers when tests were arranged in an optimal configuration. The analyzer with advanced fluidic intelligence demostrated the greatest ability to appropriately deal with an incomplete aspiration by not processing and reporting a result for the sample. This study suggests that preanalytical process-control capabilities could reduce errors. By association, it implies that similar intelligent process controls could favorably impact the error rate and, in the case of this instrument, do it without negatively impacting process throughput. Other improvements may be realized as a result of having an intelligent error-detection process including further reduction in misreported results, fewer repeats, less operator intervention, and less reagent waste.

Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors.

PubMed

Roth, Cheryl; Brewer, Melanie; Wieck, K Lynn

2017-07-01

The purpose of this study was to identify human factors associated with nursing errors. Using a Delphi technique, this study used feedback from a panel of nurse experts (n = 25) on an initial qualitative survey questionnaire followed by summarizing the results with feedback and confirmation. Synthesized factors regarding causes of errors were incorporated into a quantitative Likert-type scale, and the original expert panel participants were queried a second time to validate responses. The list identified 24 items as most common causes of nursing errors, including swamping and errors made by others that nurses are expected to recognize and fix. The responses provided a consensus top 10 errors list based on means with heavy workload and fatigue at the top of the list. The use of the Delphi survey established consensus and developed a platform upon which future study of nursing errors can evolve as a link to future solutions. This list of human factors in nursing errors should serve to stimulate dialogue among nurses about how to prevent errors and improve outcomes. Human and system failures have been the subject of an abundance of research, yet nursing errors continue to occur. © 2016 Wiley Periodicals, Inc.

Error Analysis of Indonesian Junior High School Student in Solving Space and Shape Content PISA Problem Using Newman Procedure

NASA Astrophysics Data System (ADS)

Sumule, U.; Amin, S. M.; Fuad, Y.

2018-01-01

This study aims to determine the types and causes of errors, as well as efforts being attempted to overcome the mistakes made by junior high school students in completing PISA content space and shape. Two subjects were selected based on the mathematical ability test results with the most error, yet they are able to communicate orally and in writing. Two selected subjects then worked on the PISA ability test question and the subjects were interviewed to find out the type and cause of the error and then given a scaffolding based on the type of mistake made.The results of this study obtained the type of error that students do are comprehension and transformation error. The reasons are students was not able to identify the keywords in the question, write down what is known or given, specify formulas or device a plan. To overcome this error, students were given scaffolding. Scaffolding that given to overcome misunderstandings were reviewing and restructuring. While to overcome the transformation error, scaffolding given were reviewing, restructuring, explaining and developing representational tools. Teachers are advised to use scaffolding to resolve errors so that the students are able to avoid these errors.

The determination of carbon dioxide concentration using atmospheric pressure ionization mass spectrometry/isotopic dilution and errors in concentration measurements caused by dryers.

PubMed

DeLacy, Brendan G; Bandy, Alan R

2008-01-01

An atmospheric pressure ionization mass spectrometry/isotopically labeled standard (APIMS/ILS) method has been developed for the determination of carbon dioxide (CO(2)) concentration. Descriptions of the instrumental components, the ionization chemistry, and the statistics associated with the analytical method are provided. This method represents an alternative to the nondispersive infrared (NDIR) technique, which is currently used in the atmospheric community to determine atmospheric CO(2) concentrations. The APIMS/ILS and NDIR methods exhibit a decreased sensitivity for CO(2) in the presence of water vapor. Therefore, dryers such as a nafion dryer are used to remove water before detection. The APIMS/ILS method measures mixing ratios and demonstrates linearity and range in the presence or absence of a dryer. The NDIR technique, on the other hand, measures molar concentrations. The second half of this paper describes errors in molar concentration measurements that are caused by drying. An equation describing the errors was derived from the ideal gas law, the conservation of mass, and Dalton's Law. The purpose of this derivation was to quantify errors in the NDIR technique that are caused by drying. Laboratory experiments were conducted to verify the errors created solely by the dryer in CO(2) concentration measurements post-dryer. The laboratory experiments verified the theoretically predicted errors in the derived equations. There are numerous references in the literature that describe the use of a dryer in conjunction with the NDIR technique. However, these references do not address the errors that are caused by drying.

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

Effects of errors and gaps in spatial data sets on assessment of conservation progress.

PubMed

Visconti, P; Di Marco, M; Álvarez-Romero, J G; Januchowski-Hartley, S R; Pressey, R L; Weeks, R; Rondinini, C

2013-10-01

Data on the location and extent of protected areas, ecosystems, and species' distributions are essential for determining gaps in biodiversity protection and identifying future conservation priorities. However, these data sets always come with errors in the maps and associated metadata. Errors are often overlooked in conservation studies, despite their potential negative effects on the reported extent of protection of species and ecosystems. We used 3 case studies to illustrate the implications of 3 sources of errors in reporting progress toward conservation objectives: protected areas with unknown boundaries that are replaced by buffered centroids, propagation of multiple errors in spatial data, and incomplete protected-area data sets. As of 2010, the frequency of protected areas with unknown boundaries in the World Database on Protected Areas (WDPA) caused the estimated extent of protection of 37.1% of the terrestrial Neotropical mammals to be overestimated by an average 402.8% and of 62.6% of species to be underestimated by an average 10.9%. Estimated level of protection of the world's coral reefs was 25% higher when using recent finer-resolution data on coral reefs as opposed to globally available coarse-resolution data. Accounting for additional data sets not yet incorporated into WDPA contributed up to 6.7% of additional protection to marine ecosystems in the Philippines. We suggest ways for data providers to reduce the errors in spatial and ancillary data and ways for data users to mitigate the effects of these errors on biodiversity assessments. © 2013 Society for Conservation Biology.

Errors in accident data, its types, causes and methods of rectification-analysis of the literature.

PubMed

Ahmed, Ashar; Sadullah, Ahmad Farhan Mohd; Yahya, Ahmad Shukri

2017-07-29

Most of the decisions taken to improve road safety are based on accident data, which makes it the back bone of any country's road safety system. Errors in this data will lead to misidentification of black spots and hazardous road segments, projection of false estimates pertinent to accidents and fatality rates, and detection of wrong parameters responsible for accident occurrence, thereby making the entire road safety exercise ineffective. Its extent varies from country to country depending upon various factors. Knowing the type of error in the accident data and the factors causing it enables the application of the correct method for its rectification. Therefore there is a need for a systematic literature review that addresses the topic at a global level. This paper fulfils the above research gap by providing a synthesis of literature for the different types of errors found in the accident data of 46 countries across the six regions of the world. The errors are classified and discussed with respect to each type and analysed with respect to income level; assessment with regard to the magnitude for each type is provided; followed by the different causes that result in their occurrence, and the various methods used to address each type of error. Among high-income countries the extent of error in reporting slight, severe, non-fatal and fatal injury accidents varied between 39-82%, 16-52%, 12-84%, and 0-31% respectively. For middle-income countries the error for the same categories varied between 93-98%, 32.5-96%, 34-99% and 0.5-89.5% respectively. The only four studies available for low-income countries showed that the error in reporting non-fatal and fatal accidents varied between 69-80% and 0-61% respectively. The logistic relation of error in accident data reporting, dichotomised at 50%, indicated that as the income level of a country increases the probability of having less error in accident data also increases. Average error in recording information related to the variables in the categories of location, victim's information, vehicle's information, and environment was 27%, 37%, 16% and 19% respectively. Among the causes identified for errors in accident data reporting, Policing System was found to be the most important. Overall 26 causes of errors in accident data were discussed out of which 12 were related to reporting and 14 were related to recording. "Capture-Recapture" was the most widely used method among the 11 different methods: that can be used for the rectification of under-reporting. There were 12 studies pertinent to the rectification of accident location and almost all of them utilised a Geographical Information System (GIS) platform coupled with a matching algorithm to estimate the correct location. It is recommended that the policing system should be reformed and public awareness should be created to help reduce errors in accident data. Copyright © 2017 Elsevier Ltd. All rights reserved.

Film thickness measurement based on nonlinear phase analysis using a Linnik microscopic white-light spectral interferometer.

PubMed

Guo, Tong; Chen, Zhuo; Li, Minghui; Wu, Juhong; Fu, Xing; Hu, Xiaotang

2018-04-20

Based on white-light spectral interferometry and the Linnik microscopic interference configuration, the nonlinear phase components of the spectral interferometric signal were analyzed for film thickness measurement. The spectral interferometric signal was obtained using a Linnik microscopic white-light spectral interferometer, which includes the nonlinear phase components associated with the effective thickness, the nonlinear phase error caused by the double-objective lens, and the nonlinear phase of the thin film itself. To determine the influence of the effective thickness, a wavelength-correction method was proposed that converts the effective thickness into a constant value; the nonlinear phase caused by the effective thickness can then be determined and subtracted from the total nonlinear phase. A method for the extraction of the nonlinear phase error caused by the double-objective lens was also proposed. Accurate thickness measurement of a thin film can be achieved by fitting the nonlinear phase of the thin film after removal of the nonlinear phase caused by the effective thickness and by the nonlinear phase error caused by the double-objective lens. The experimental results demonstrated that both the wavelength-correction method and the extraction method for the nonlinear phase error caused by the double-objective lens improve the accuracy of film thickness measurements.

Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors.

PubMed

Kostopoulou, Olga; Delaney, Brendan

2007-04-01

To classify events of actual or potential harm to primary care patients using a multilevel taxonomy of cognitive and system factors. Observational study of patient safety events obtained via a confidential but not anonymous reporting system. Reports were followed up with interviews where necessary. Events were analysed for their causes and contributing factors using causal trees and were classified using the taxonomy. Five general medical practices in the West Midlands were selected to represent a range of sizes and types of patient population. All practice staff were invited to report patient safety events. Main outcome measures were frequencies of clinical types of events reported, cognitive types of error, types of detection and contributing factors; and relationship between types of error, practice size, patient consequences and detection. 78 reports were relevant to patient safety and analysable. They included 21 (27%) adverse events and 50 (64%) near misses. 16.7% (13/71) had serious patient consequences, including one death. 75.7% (59/78) had the potential for serious patient harm. Most reports referred to administrative errors (25.6%, 20/78). 60% (47/78) of the reports contained sufficient information to characterise cognition: "situation assessment and response selection" was involved in 45% (21/47) of these reports and was often linked to serious potential consequences. The most frequent contributing factor was work organisation, identified in 71 events. This included excessive task demands (47%, 37/71) and fragmentation (28%, 22/71). Even though most reported events were near misses, events with serious patient consequences were also reported. Failures in situation assessment and response selection, a cognitive activity that occurs in both clinical and administrative tasks, was related to serious potential harm.

Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors

PubMed Central

Kostopoulou, Olga; Delaney, Brendan

2007-01-01

Objective To classify events of actual or potential harm to primary care patients using a multilevel taxonomy of cognitive and system factors. Methods Observational study of patient safety events obtained via a confidential but not anonymous reporting system. Reports were followed up with interviews where necessary. Events were analysed for their causes and contributing factors using causal trees and were classified using the taxonomy. Five general medical practices in the West Midlands were selected to represent a range of sizes and types of patient population. All practice staff were invited to report patient safety events. Main outcome measures were frequencies of clinical types of events reported, cognitive types of error, types of detection and contributing factors; and relationship between types of error, practice size, patient consequences and detection. Results 78 reports were relevant to patient safety and analysable. They included 21 (27%) adverse events and 50 (64%) near misses. 16.7% (13/71) had serious patient consequences, including one death. 75.7% (59/78) had the potential for serious patient harm. Most reports referred to administrative errors (25.6%, 20/78). 60% (47/78) of the reports contained sufficient information to characterise cognition: “situation assessment and response selection” was involved in 45% (21/47) of these reports and was often linked to serious potential consequences. The most frequent contributing factor was work organisation, identified in 71 events. This included excessive task demands (47%, 37/71) and fragmentation (28%, 22/71). Conclusions Even though most reported events were near misses, events with serious patient consequences were also reported. Failures in situation assessment and response selection, a cognitive activity that occurs in both clinical and administrative tasks, was related to serious potential harm. PMID:17403753

Package Design Affects Accuracy Recognition for Medications.

PubMed

Endestad, Tor; Wortinger, Laura A; Madsen, Steinar; Hortemo, Sigurd

2016-12-01

Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors. An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors. In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated. The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications. Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications. A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose. © 2016, Human Factors and Ergonomics Society.

Syndromic surveillance for health information system failures: a feasibility study.

PubMed

Ong, Mei-Sing; Magrabi, Farah; Coiera, Enrico

2013-05-01

To explore the applicability of a syndromic surveillance method to the early detection of health information technology (HIT) system failures. A syndromic surveillance system was developed to monitor a laboratory information system at a tertiary hospital. Four indices were monitored: (1) total laboratory records being created; (2) total records with missing results; (3) average serum potassium results; and (4) total duplicated tests on a patient. The goal was to detect HIT system failures causing: data loss at the record level; data loss at the field level; erroneous data; and unintended duplication of data. Time-series models of the indices were constructed, and statistical process control charts were used to detect unexpected behaviors. The ability of the models to detect HIT system failures was evaluated using simulated failures, each lasting for 24 h, with error rates ranging from 1% to 35%. In detecting data loss at the record level, the model achieved a sensitivity of 0.26 when the simulated error rate was 1%, while maintaining a specificity of 0.98. Detection performance improved with increasing error rates, achieving a perfect sensitivity when the error rate was 35%. In the detection of missing results, erroneous serum potassium results and unintended repetition of tests, perfect sensitivity was attained when the error rate was as small as 5%. Decreasing the error rate to 1% resulted in a drop in sensitivity to 0.65-0.85. Syndromic surveillance methods can potentially be applied to monitor HIT systems, to facilitate the early detection of failures.

Package Design Affects Accuracy Recognition for Medications

PubMed Central

Endestad, Tor; Wortinger, Laura A.; Madsen, Steinar; Hortemo, Sigurd

2016-01-01

Objective: Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors. Background: An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors. Method: In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated. Results: The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications. Conclusion: Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications. Application: A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose. PMID:27591209

Non-linear matter power spectrum covariance matrix errors and cosmological parameter uncertainties

NASA Astrophysics Data System (ADS)

Blot, L.; Corasaniti, P. S.; Amendola, L.; Kitching, T. D.

2016-06-01

The covariance of the matter power spectrum is a key element of the analysis of galaxy clustering data. Independent realizations of observational measurements can be used to sample the covariance, nevertheless statistical sampling errors will propagate into the cosmological parameter inference potentially limiting the capabilities of the upcoming generation of galaxy surveys. The impact of these errors as function of the number of realizations has been previously evaluated for Gaussian distributed data. However, non-linearities in the late-time clustering of matter cause departures from Gaussian statistics. Here, we address the impact of non-Gaussian errors on the sample covariance and precision matrix errors using a large ensemble of N-body simulations. In the range of modes where finite volume effects are negligible (0.1 ≲ k [h Mpc-1] ≲ 1.2), we find deviations of the variance of the sample covariance with respect to Gaussian predictions above ˜10 per cent at k > 0.3 h Mpc-1. Over the entire range these reduce to about ˜5 per cent for the precision matrix. Finally, we perform a Fisher analysis to estimate the effect of covariance errors on the cosmological parameter constraints. In particular, assuming Euclid-like survey characteristics we find that a number of independent realizations larger than 5000 is necessary to reduce the contribution of sampling errors to the cosmological parameter uncertainties at subpercent level. We also show that restricting the analysis to large scales k ≲ 0.2 h Mpc-1 results in a considerable loss in constraining power, while using the linear covariance to include smaller scales leads to an underestimation of the errors on the cosmological parameters.

PREVALENCE OF UNCORRECTED REFRACTIVE ERRORS IN ADULTS AGED 30 YEARS AND ABOVE IN A RURAL POPULATION IN PAKISTAN.

PubMed

Abdullah, Ayesha S; Jadoon, Milhammad Zahid; Akram, Mohammad; Awan, Zahid Hussain; Azam, Mohammad; Safdar, Mohammad; Nigar, Mohammad

2015-01-01

Uncorrected refractive errors are a leading cause of visual disability globally. This population-based study was done to estimate the prevalence of uncorrected refractive errors in adults aged 30 years and above of village Pawakah, Khyber Pakhtunkhwa (KPK), Pakistan. It was a cross-sectional survey in which 1000 individuals were included randomly. All the individuals were screened for uncorrected refractive errors and those whose visual acuity (VA) was found to be less than 6/6 were refracted. In whom refraction was found to be unsatisfactory (i.e., a best corrected visual acuity of <6/6) further examination was done to establish the cause for the subnormal vision. A total of 917 subjects participated in the survey (response rate 92%). The prevalence of uncorrected refractive errors was found to be 23.97% among males and 20% among females. The prevalence of visually disabling refractive errors was 6.89% in males and 5.71% in females. The prevalence was seen to increase with age, with maximum prevalence in 51-60 years age group. Hypermetropia (10.14%) was found to be the commonest refractive error followed by Myopia (6.00%) and Astigmatism (5.6%). The prevalence of Presbyopia was 57.5% (60.45% in males and 55.23% in females). Poor affordability was the commonest barrier to the use of spectacles, followed by unawareness. Cataract was the commonest reason for impaired vision after refractive correction. The prevalence of blindness was 1.96% (1.53% in males and 2.28% in females) in this community with cataract as the commonest cause. Despite being the most easily avoidable cause of subnormal vision uncorrected refractive errors still account for a major proportion of the burden of decreased vision in this area. Effective measures for the screening and affordable correction of uncorrected refractive errors need to be incorpora'ted into the health care delivery system.

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

Development of an Ontology to Model Medical Errors, Information Needs, and the Clinical Communication Space

PubMed Central

Stetson, Peter D.; McKnight, Lawrence K.; Bakken, Suzanne; Curran, Christine; Kubose, Tate T.; Cimino, James J.

2002-01-01

Medical errors are common, costly and often preventable. Work in understanding the proximal causes of medical errors demonstrates that systems failures predispose to adverse clinical events. Most of these systems failures are due to lack of appropriate information at the appropriate time during the course of clinical care. Problems with clinical communication are common proximal causes of medical errors. We have begun a project designed to measure the impact of wireless computing on medical errors. We report here on our efforts to develop an ontology representing the intersection of medical errors, information needs and the communication space. We will use this ontology to support the collection, storage and interpretation of project data. The ontology’s formal representation of the concepts in this novel domain will help guide the rational deployment of our informatics interventions. A real-life scenario is evaluated using the ontology in order to demonstrate its utility.

The importance of intra-hospital pharmacovigilance in the detection of medication errors

PubMed

Villegas, Francisco; Figueroa-Montero, David; Barbero-Becerra, Varenka; Juárez-Hernández, Eva; Uribe, Misael; Chávez-Tapia, Norberto; González-Chon, Octavio

2018-01-01

Hospitalized patients are susceptible to medication errors, which represent between the fourth and the sixth cause of death. The department of intra-hospital pharmacovigilance intervenes in the entire process of medication with the purpose to prevent, repair and assess damages. To analyze medication errors reported by Mexican Fundación Clínica Médica Sur pharmacovigilance system and their impact on patients. Prospective study carried out from 2012 to 2015, where medication prescriptions given to patients were recorded. Owing to heterogeneity, data were described as absolute numbers in a logarithmic scale. 292 932 prescriptions of 56 368 patients were analyzed, and 8.9% of medication errors were identified. The treating physician was responsible of 83.32% of medication errors, residents of 6.71% and interns of 0.09%. No error caused permanent damage or death. This is the pharmacovigilance study with the largest sample size reported. Copyright: © 2018 SecretarÍa de Salud.

Error mechanism analyses of an ultra-precision stage for high speed scan motion over a large stroke

NASA Astrophysics Data System (ADS)

Wang, Shaokai; Tan, Jiubin; Cui, Jiwen

2015-02-01

Reticle Stage (RS) is designed to complete scan motion with high speed in nanometer-scale over a large stroke. Comparing with the allowable scan accuracy of a few nanometers, errors caused by any internal or external disturbances are critical and must not be ignored. In this paper, RS is firstly introduced in aspects of mechanical structure, forms of motion, and controlling method. Based on that, mechanisms of disturbances transferred to final servo-related error in scan direction are analyzed, including feedforward error, coupling between the large stroke stage (LS) and the short stroke stage (SS), and movement of measurement reference. Especially, different forms of coupling between SS and LS are discussed in detail. After theoretical analysis above, the contributions of these disturbances to final error are simulated numerically. The residual positioning error caused by feedforward error in acceleration process is about 2 nm after settling time, the coupling between SS and LS about 2.19 nm, and the movements of MF about 0.6 nm.

[Refractive errors as causes of visual impairment in children from public schools of the Botucatu region - SP].

PubMed

Oliveira, Claudia Akemi Shiratori de; Hisatomi, Kenia Scrocaro; Leite, Cristiano Pinheiro; Schellini, Silvana Artioli; Padovani, Carlos Roberto; Padovani, Carlos Roberto Pereira

2009-01-01

To evaluate the refractive errors as cause of visual impairment in school children from the Botucatu region. A sectional study was conducted evaluating preschool and elementary school students, according to gender, refractive error, visual acuity and treatment. Four thousand six hundred and twenty-three (4,623) children were submitted to visual acuity evaluation and 8.1% of them were submitted to complete ocular examination. There were 63.2% hyperopic astigmatism, 15.7% myopic astigmatism, 12.5% astigmatism, 4.9% hyperopia and 3.7% myopia. Corrective lenses were prescribed for 48.7% of the evaluated children. The most frequent refractive error was hyperopic astigmatism and 50% of the children received treatment. The frequency of refractive errors was 3.9% of the studied population.

Special Issue on Uncertainty Quantification in Multiscale System Design and Simulation

DOE PAGES

Wang, Yan; Swiler, Laura

2017-09-07

The importance of uncertainty has been recognized in various modeling, simulation, and analysis applications, where inherent assumptions and simplifications affect the accuracy of model predictions for physical phenomena. As model predictions are now heavily relied upon for simulation-based system design, which includes new materials, vehicles, mechanical and civil structures, and even new drugs, wrong model predictions could potentially cause catastrophic consequences. Therefore, uncertainty and associated risks due to model errors should be quantified to support robust systems engineering.

Special Issue on Uncertainty Quantification in Multiscale System Design and Simulation

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

Wang, Yan; Swiler, Laura

The importance of uncertainty has been recognized in various modeling, simulation, and analysis applications, where inherent assumptions and simplifications affect the accuracy of model predictions for physical phenomena. As model predictions are now heavily relied upon for simulation-based system design, which includes new materials, vehicles, mechanical and civil structures, and even new drugs, wrong model predictions could potentially cause catastrophic consequences. Therefore, uncertainty and associated risks due to model errors should be quantified to support robust systems engineering.

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…

Information-Gathering Patterns Associated with Higher Rates of Diagnostic Error

ERIC Educational Resources Information Center

Delzell, John E., Jr.; Chumley, Heidi; Webb, Russell; Chakrabarti, Swapan; Relan, Anju

2009-01-01

Diagnostic errors are an important source of medical errors. Problematic information-gathering is a common cause of diagnostic errors among physicians and medical students. The objectives of this study were to (1) determine if medical students' information-gathering patterns formed clusters of similar strategies, and if so (2) to calculate the…

A retrospective review of medical errors adjudicated in court between 2002 and 2012 in Spain.

PubMed

Giraldo, Priscila; Sato, Luke; Sala, María; Comas, Merce; Dywer, Kathy; Castells, Xavier

2016-02-01

This paper describes verdicts in court involving injury-producing medical errors in Spain. A descriptive analysis of 1041 closed court verdicts from Spain between January 2002 and December 2012. It was determined whether a medical error had occurred, and among those with medical error (n = 270), characteristics and results of litigation were analyzed. Data on litigation were obtained from the Thomson Reuters Aranzadi Westlaw databases. All verdicts involving health system were reviewed and classified according to the presence of medical error. Among those, contributory factors, medical specialty involved, health impact (death, disability and severity) and results of litigation (resolution, time to verdict and economic compensations) were described. Medical errors were involved in 25.9% of court verdicts. The cause of medical error was a diagnosis-related problem in 25.1% and surgical treatment in 22.2%, and Obstetrics-Gynecology was the most frequent involved specialty (21%). Most of them were of high severity (59.4%), one-third (32%) caused death. The average time interval between the occurrence of the error and the verdict was 7.8 years. The average indemnity payment was €239 505.24; the highest was psychiatry (€7 585 075.86) and the lowest was Emergency Medicine (€69 871.19). This study indicates that in Spain medical errors are common among verdicts involving the health system, most of them causing high-severity adverse outcomes. The interval between the medical error and the verdict is excessive, and there is a wide range of economic compensation. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project.

PubMed

Buchini, Sara; Quattrin, Rosanna

2012-04-01

To record the frequency of interruptions and their causes, to identify 'avoidable' interruptions and to build an improvement project to reduce 'avoidable' interruptions. In Italy each year 30,000-35,000 deaths per year are attributed to health-care system errors, of which 19% are caused by medication errors. The factors that contribute to drug management error also include interruptions and carelessness during treatment administration. A descriptive study design was used to record the frequency of interruptions and their causes and to identify 'avoidable' interruptions in an intensive rehabilitation ward in Northern Italy. A data collection grid was used to record the data over a 6-month period. A total of 3000 work hours were observed. During the study period 1170 interruptions were observed. The study identified 14 causes of interruption. The study shows that of the 14 cases of interruptions at least nine can be defined as 'avoidable'. An improvement project has been proposed to reduce unnecessary interruptions and distractions to avoid making errors. An additional useful step to reduce the incidence of treatment errors would be to implement the use of a single patient medication sheet for the recording of drug prescription, preparation and administration and also the incident reporting. © 2011 Blackwell Publishing Ltd.

[Statistical Process Control (SPC) can help prevent treatment errors without increasing costs in radiotherapy].

PubMed

Govindarajan, R; Llueguera, E; Melero, A; Molero, J; Soler, N; Rueda, C; Paradinas, C

2010-01-01

Statistical Process Control (SPC) was applied to monitor patient set-up in radiotherapy and, when the measured set-up error values indicated a loss of process stability, its root cause was identified and eliminated to prevent set-up errors. Set up errors were measured for medial-lateral (ml), cranial-caudal (cc) and anterior-posterior (ap) dimensions and then the upper control limits were calculated. Once the control limits were known and the range variability was acceptable, treatment set-up errors were monitored using sub-groups of 3 patients, three times each shift. These values were plotted on a control chart in real time. Control limit values showed that the existing variation was acceptable. Set-up errors, measured and plotted on a X chart, helped monitor the set-up process stability and, if and when the stability was lost, treatment was interrupted, the particular cause responsible for the non-random pattern was identified and corrective action was taken before proceeding with the treatment. SPC protocol focuses on controlling the variability due to assignable cause instead of focusing on patient-to-patient variability which normally does not exist. Compared to weekly sampling of set-up error in each and every patient, which may only ensure that just those sampled sessions were set-up correctly, the SPC method enables set-up error prevention in all treatment sessions for all patients and, at the same time, reduces the control costs. Copyright © 2009 SECA. Published by Elsevier Espana. All rights reserved.

Self-assessing target with automatic feedback

DOEpatents

Larkin, Stephen W.; Kramer, Robert L.

2004-03-02

A self assessing target with four quadrants and a method of use thereof. Each quadrant containing possible causes for why shots are going into that particular quadrant rather than the center mass of the target. Each possible cause is followed by a solution intended to help the marksman correct the problem causing the marksman to shoot in that particular area. In addition, the self assessing target contains possible causes for general shooting errors and solutions to the causes of the general shooting error. The automatic feedback with instant suggestions and corrections enables the shooter to improve their marksmanship.

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.

Circular Array of Magnetic Sensors for Current Measurement: Analysis for Error Caused by Position of Conductor.

PubMed

Yu, Hao; Qian, Zheng; Liu, Huayi; Qu, Jiaqi

2018-02-14

This paper analyzes the measurement error, caused by the position of the current-carrying conductor, of a circular array of magnetic sensors for current measurement. The circular array of magnetic sensors is an effective approach for AC or DC non-contact measurement, as it is low-cost, light-weight, has a large linear range, wide bandwidth, and low noise. Especially, it has been claimed that such structure has excellent reduction ability for errors caused by the position of the current-carrying conductor, crosstalk current interference, shape of the conduction cross-section, and the Earth's magnetic field. However, the positions of the current-carrying conductor-including un-centeredness and un-perpendicularity-have not been analyzed in detail until now. In this paper, for the purpose of having minimum measurement error, a theoretical analysis has been proposed based on vector inner and exterior product. In the presented mathematical model of relative error, the un-center offset distance, the un-perpendicular angle, the radius of the circle, and the number of magnetic sensors are expressed in one equation. The comparison of the relative error caused by the position of the current-carrying conductor between four and eight sensors is conducted. Tunnel magnetoresistance (TMR) sensors are used in the experimental prototype to verify the mathematical model. The analysis results can be the reference to design the details of the circular array of magnetic sensors for current measurement in practical situations.

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

Newman, Jennifer F.; Clifton, Andrew

Currently, cup anemometers on meteorological towers are used to measure wind speeds and turbulence intensity to make decisions about wind turbine class and site suitability; however, as modern turbine hub heights increase and wind energy expands to complex and remote sites, it becomes more difficult and costly to install meteorological towers at potential sites. As a result, remote-sensing devices (e.g., lidars) are now commonly used by wind farm managers and researchers to estimate the flow field at heights spanned by a turbine. Although lidars can accurately estimate mean wind speeds and wind directions, there is still a large amount ofmore » uncertainty surrounding the measurement of turbulence using these devices. Errors in lidar turbulence estimates are caused by a variety of factors, including instrument noise, volume averaging, and variance contamination, in which the magnitude of these factors is highly dependent on measurement height and atmospheric stability. As turbulence has a large impact on wind power production, errors in turbulence measurements will translate into errors in wind power prediction. The impact of using lidars rather than cup anemometers for wind power prediction must be understood if lidars are to be considered a viable alternative to cup anemometers.In this poster, the sensitivity of power prediction error to typical lidar turbulence measurement errors is assessed. Turbulence estimates from a vertically profiling WINDCUBE v2 lidar are compared to high-resolution sonic anemometer measurements at field sites in Oklahoma and Colorado to determine the degree of lidar turbulence error that can be expected under different atmospheric conditions. These errors are then incorporated into a power prediction model to estimate the sensitivity of power prediction error to turbulence measurement error. Power prediction models, including the standard binning method and a random forest method, were developed using data from the aeroelastic simulator FAST for a 1.5 MW turbine. The impact of lidar turbulence error on the predicted power from these different models is examined to determine the degree of turbulence measurement accuracy needed for accurate power prediction.« less

Study on the Rationality and Validity of Probit Models of Domino Effect to Chemical Process Equipment caused by Overpressure

NASA Astrophysics Data System (ADS)

Sun, Dongliang; Huang, Guangtuan; Jiang, Juncheng; Zhang, Mingguang; Wang, Zhirong

2013-04-01

Overpressure is one important cause of domino effect in accidents of chemical process equipments. Some models considering propagation probability and threshold values of the domino effect caused by overpressure have been proposed in previous study. In order to prove the rationality and validity of the models reported in the reference, two boundary values of three damage degrees reported were considered as random variables respectively in the interval [0, 100%]. Based on the overpressure data for damage to the equipment and the damage state, and the calculation method reported in the references, the mean square errors of the four categories of damage probability models of overpressure were calculated with random boundary values, and then a relationship of mean square error vs. the two boundary value was obtained, the minimum of mean square error was obtained, compared with the result of the present work, mean square error decreases by about 3%. Therefore, the error was in the acceptable range of engineering applications, the models reported can be considered reasonable and valid.

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 chemical quality testing are needed.

Testing accelerometer rectification error caused by multidimensional composite inputs with double turntable centrifuge.

PubMed

Guan, W; Meng, X F; Dong, X M

2014-12-01

Rectification error is a critical characteristic of inertial accelerometers. Accelerometers working in operational situations are stimulated by composite inputs, including constant acceleration and vibration, from multiple directions. However, traditional methods for evaluating rectification error only use one-dimensional vibration. In this paper, a double turntable centrifuge (DTC) was utilized to produce the constant acceleration and vibration simultaneously and we tested the rectification error due to the composite accelerations. At first, we deduced the expression of the rectification error with the output of the DTC and a static model of the single-axis pendulous accelerometer under test. Theoretical investigation and analysis were carried out in accordance with the rectification error model. Then a detailed experimental procedure and testing results were described. We measured the rectification error with various constant accelerations at different frequencies and amplitudes of the vibration. The experimental results showed the distinguished characteristics of the rectification error caused by the composite accelerations. The linear relation between the constant acceleration and the rectification error was proved. The experimental procedure and results presented in this context can be referenced for the investigation of the characteristics of accelerometer with multiple inputs.

Human error and human factors engineering in health care.

PubMed

Welch, D L

1997-01-01

Human error is inevitable. It happens in health care systems as it does in all other complex systems, and no measure of attention, training, dedication, or punishment is going to stop it. The discipline of human factors engineering (HFE) has been dealing with the causes and effects of human error since the 1940's. Originally applied to the design of increasingly complex military aircraft cockpits, HFE has since been effectively applied to the problem of human error in such diverse systems as nuclear power plants, NASA spacecraft, the process control industry, and computer software. Today the health care industry is becoming aware of the costs of human error and is turning to HFE for answers. Just as early experimental psychologists went beyond the label of "pilot error" to explain how the design of cockpits led to air crashes, today's HFE specialists are assisting the health care industry in identifying the causes of significant human errors in medicine and developing ways to eliminate or ameliorate them. This series of articles will explore the nature of human error and how HFE can be applied to reduce the likelihood of errors and mitigate their effects.

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

Medication errors: an overview for clinicians.

PubMed

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

2014-08-01

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

Results of the first complete static calibration of the RSRA rotor-load-measurement system

NASA Technical Reports Server (NTRS)

Acree, C. W., Jr.

1984-01-01

The compound Rotor System Research Aircraft (RSRA) is designed to make high-accuracy, simultaneous measurements of all rotor forces and moments in flight. Physical calibration of the rotor force- and moment-measurement system when installed in the aircraft is required to account for known errors and to ensure that measurement-system accuracy is traceable to the National Bureau of Standards. The first static calibration and associated analysis have been completed with good results. Hysteresis was a potential cause of static calibration errors, but was found to be negligible in flight compared to full-scale loads, and analytical methods have been devised to eliminate hysteresis effects on calibration data. Flight tests confirmed that the calibrated rotor-load-measurement system performs as expected in flight and that it can dependably make direct measurements of fuselage vertical drag in hover.

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

Bachman, Daniel; Chen, Zhijiang; Wang, Christopher

Phase errors caused by fabrication variations in silicon photonic integrated circuits are an important problem, which negatively impacts device yield and performance. This study reports our recent progress in the development of a method for permanent, postfabrication phase error correction of silicon photonic circuits based on femtosecond laser irradiation. Using beam shaping technique, we achieve a 14-fold enhancement in the phase tuning resolution of the method with a Gaussian-shaped beam compared to a top-hat beam. The large improvement in the tuning resolution makes the femtosecond laser method potentially useful for very fine phase trimming of silicon photonic circuits. Finally, wemore » also show that femtosecond laser pulses can directly modify silicon photonic devices through a SiO 2 cladding layer, making it the only permanent post-fabrication method that can tune silicon photonic circuits protected by an oxide cladding.« less

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

NASA Astrophysics Data System (ADS)

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

2018-05-01

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

Algorithm design for automated transportation photo enforcement camera image and video quality diagnostic check modules

NASA Astrophysics Data System (ADS)

Raghavan, Ajay; Saha, Bhaskar

2013-03-01

Photo enforcement devices for traffic rules such as red lights, toll, stops, and speed limits are increasingly being deployed in cities and counties around the world to ensure smooth traffic flow and public safety. These are typically unattended fielded systems, and so it is important to periodically check them for potential image/video quality problems that might interfere with their intended functionality. There is interest in automating such checks to reduce the operational overhead and human error involved in manually checking large camera device fleets. Examples of problems affecting such camera devices include exposure issues, focus drifts, obstructions, misalignment, download errors, and motion blur. Furthermore, in some cases, in addition to the sub-algorithms for individual problems, one also has to carefully design the overall algorithm and logic to check for and accurately classifying these individual problems. Some of these issues can occur in tandem or have the potential to be confused for each other by automated algorithms. Examples include camera misalignment that can cause some scene elements to go out of focus for wide-area scenes or download errors that can be misinterpreted as an obstruction. Therefore, the sequence in which the sub-algorithms are utilized is also important. This paper presents an overview of these problems along with no-reference and reduced reference image and video quality solutions to detect and classify such faults.

Acute rhabdomyolysis and inflammation.

PubMed

Hamel, Yamina; Mamoune, Asmaa; Mauvais, François-Xavier; Habarou, Florence; Lallement, Laetitia; Romero, Norma Beatriz; Ottolenghi, Chris; de Lonlay, Pascale

2015-07-01

Rhabdomyolysis results from the rapid breakdown of skeletal muscle fibers, which leads to leakage of potentially toxic cellular content into the systemic circulation. Acquired causes by direct injury to the sarcolemma are most frequent. The inherited causes are: i) metabolic with failure of energy production, including mitochondrial fatty acid ß-oxidation defects, LPIN1 mutations, inborn errors of glycogenolysis and glycolysis, more rarely mitochondrial respiratory chain deficiency, purine defects and peroxysomal α-methyl-acyl-CoA-racemase defect (AMACR), ii) structural causes with muscle dystrophies and myopathies, iii) calcium pump disorder with RYR1 gene mutations, iv) inflammatory causes with myositis. Irrespective of the cause of rhabdomyolysis, the pathology follows a common pathway, either by the direct injury to sarcolemma by increased intracellular calcium concentration (acquired causes) or by the failure of energy production (inherited causes), which leads to fiber necrosis. Rhabdomyolysis are frequently precipitated by febrile illness or exercise. These conditions are associated with two events, elevated temperature and high circulating levels of pro-inflammatory mediators such as cytokines and chemokines. To illustrate these points in the context of energy metabolism, protein thermolability and the potential benefits of arginine therapy, we focus on a rare cause of rhabdomyolysis, aldolase A deficiency. In addition, our studies on lipin-1 (LPIN1) deficiency raise the possibility that several diseases involved in rhabdomyolysis implicate pro-inflammatory cytokines and may even represent primarily pro-inflammatory diseases. Thus, not only thermolability of mutant proteins critical for muscle function, but also pro-inflammatory cytokines per se, may lead to metabolic decompensation and rhabdomyolysis.

Investigation of technology needs for avoiding helicopter pilot error related accidents

NASA Technical Reports Server (NTRS)

Chais, R. I.; Simpson, W. E.

1985-01-01

Pilot error which is cited as a cause or related factor in most rotorcraft accidents was examined. Pilot error related accidents in helicopters to identify areas in which new technology could reduce or eliminate the underlying causes of these human errors were investigated. The aircraft accident data base at the U.S. Army Safety Center was studied as the source of data on helicopter accidents. A randomly selected sample of 110 aircraft records were analyzed on a case-by-case basis to assess the nature of problems which need to be resolved and applicable technology implications. Six technology areas in which there appears to be a need for new or increased emphasis are identified.

Searching for the Final Answer: Factors Contributing to Medication Administration Errors.

ERIC Educational Resources Information Center

Pape, Tess M.

2001-01-01

Causal factors contributing to errors in medication administration should be thoroughly investigated, focusing on systems rather than individual nurses. Unless systemic causes are addressed, many errors will go unreported for fear of reprisal. (Contains 42 references.) (SK)

Death certificate completion skills of hospital physicians in a developing country.

PubMed

Haque, Ahmed Suleman; Shamim, Kanza; Siddiqui, Najm Hasan; Irfan, Muhammad; Khan, Javaid Ahmed

2013-06-06

Death certificates (DC) can provide valuable health status data regarding disease incidence, prevalence and mortality in a community. It can guide local health policy and help in setting priorities. Incomplete and inaccurate DC data, on the other hand, can significantly impair the precision of a national health information database. In this study we evaluated the accuracy of death certificates at a tertiary care teaching hospital in a Karachi, Pakistan. A retrospective study conducted at Aga Khan University Hospital, Karachi, Pakistan for a period of six months. Medical records and death certificates of all patients who died under adult medical service were studied. The demographic characteristics, administrative details, co-morbidities and cause of death from death certificates were collected using an approved standardized form. Accuracy of this information was validated using their medical records. Errors in the death certificates were classified into six categories, from 0 to 5 according to increasing severity; a grade 0 was assigned if no errors were identified, and 5, if an incorrect cause of death was attributed or placed in an improper sequence. 223 deaths occurred during the study period. 9 certificates were not accessible and 12 patients had incomplete medical records. 202 certificates were finally analyzed. Most frequent errors pertaining to patients' demographics (92%) and cause/s of death (87%) were identified. 156 (77%) certificates had 3 or more errors and 124 (62%) certificates had a combination of errors that significantly changed the death certificate interpretation. Only 1% certificates were error free. A very high rate of errors was identified in death certificates completed at our academic institution. There is a pressing need for appropriate intervention/s to resolve this important issue.

Persistent damaged bases in DNA allow mutagenic break repair in Escherichia coli.

PubMed

Moore, Jessica M; Correa, Raul; Rosenberg, Susan M; Hastings, P J

2017-07-01

Bacteria, yeast and human cancer cells possess mechanisms of mutagenesis upregulated by stress responses. Stress-inducible mutagenesis potentially accelerates adaptation, and may provide important models for mutagenesis that drives cancers, host pathogen interactions, antibiotic resistance and possibly much of evolution generally. In Escherichia coli repair of double-strand breaks (DSBs) becomes mutagenic, using low-fidelity DNA polymerases under the control of the SOS DNA-damage response and RpoS general stress response, which upregulate and allow the action of error-prone DNA polymerases IV (DinB), II and V to make mutations during repair. Pol IV is implied to compete with and replace high-fidelity DNA polymerases at the DSB-repair replisome, causing mutagenesis. We report that up-regulated Pol IV is not sufficient for mutagenic break repair (MBR); damaged bases in the DNA are also required, and that in starvation-stressed cells, these are caused by reactive-oxygen species (ROS). First, MBR is reduced by either ROS-scavenging agents or constitutive activation of oxidative-damage responses, both of which reduce cellular ROS levels. The ROS promote MBR other than by causing DSBs, saturating mismatch repair, oxidizing proteins, or inducing the SOS response or the general stress response. We find that ROS drive MBR through oxidized guanines (8-oxo-dG) in DNA, in that overproduction of a glycosylase that removes 8-oxo-dG from DNA prevents MBR. Further, other damaged DNA bases can substitute for 8-oxo-dG because ROS-scavenged cells resume MBR if either DNA pyrimidine dimers or alkylated bases are induced. We hypothesize that damaged bases in DNA pause the replisome and allow the critical switch from high fidelity to error-prone DNA polymerases in the DSB-repair replisome, thus allowing MBR. The data imply that in addition to the indirect stress-response controlled switch to MBR, a direct cis-acting switch to MBR occurs independently of DNA breakage, caused by ROS oxidation of DNA potentially regulated by ROS regulators.

Persistent damaged bases in DNA allow mutagenic break repair in Escherichia coli

PubMed Central

Moore, Jessica M.; Correa, Raul; Rosenberg, Susan M.

2017-01-01

Bacteria, yeast and human cancer cells possess mechanisms of mutagenesis upregulated by stress responses. Stress-inducible mutagenesis potentially accelerates adaptation, and may provide important models for mutagenesis that drives cancers, host pathogen interactions, antibiotic resistance and possibly much of evolution generally. In Escherichia coli repair of double-strand breaks (DSBs) becomes mutagenic, using low-fidelity DNA polymerases under the control of the SOS DNA-damage response and RpoS general stress response, which upregulate and allow the action of error-prone DNA polymerases IV (DinB), II and V to make mutations during repair. Pol IV is implied to compete with and replace high-fidelity DNA polymerases at the DSB-repair replisome, causing mutagenesis. We report that up-regulated Pol IV is not sufficient for mutagenic break repair (MBR); damaged bases in the DNA are also required, and that in starvation-stressed cells, these are caused by reactive-oxygen species (ROS). First, MBR is reduced by either ROS-scavenging agents or constitutive activation of oxidative-damage responses, both of which reduce cellular ROS levels. The ROS promote MBR other than by causing DSBs, saturating mismatch repair, oxidizing proteins, or inducing the SOS response or the general stress response. We find that ROS drive MBR through oxidized guanines (8-oxo-dG) in DNA, in that overproduction of a glycosylase that removes 8-oxo-dG from DNA prevents MBR. Further, other damaged DNA bases can substitute for 8-oxo-dG because ROS-scavenged cells resume MBR if either DNA pyrimidine dimers or alkylated bases are induced. We hypothesize that damaged bases in DNA pause the replisome and allow the critical switch from high fidelity to error-prone DNA polymerases in the DSB-repair replisome, thus allowing MBR. The data imply that in addition to the indirect stress-response controlled switch to MBR, a direct cis-acting switch to MBR occurs independently of DNA breakage, caused by ROS oxidation of DNA potentially regulated by ROS regulators. PMID:28727736

Medication Errors in Vietnamese Hospitals: Prevalence, Potential Outcome and Associated Factors

PubMed Central

Nguyen, Huong-Thao; Nguyen, Tuan-Dung; van den Heuvel, Edwin R.; Haaijer-Ruskamp, Flora M.; Taxis, Katja

2015-01-01

Background Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam. Objectives To determine the prevalence and potential clinical outcome of medication preparation and administration errors, and to identify factors associated with errors. Methods This was a prospective study conducted on six wards in two urban public hospitals in Vietnam. Data of preparation and administration errors of oral and intravenous medications was collected by direct observation, 12 hours per day on 7 consecutive days, on each ward. Multivariable logistic regression was applied to identify factors contributing to errors. Results In total, 2060 out of 5271 doses had at least one error. The error rate was 39.1% (95% confidence interval 37.8%- 40.4%). Experts judged potential clinical outcomes as minor, moderate, and severe in 72 (1.4%), 1806 (34.2%) and 182 (3.5%) doses. Factors associated with errors were drug characteristics (administration route, complexity of preparation, drug class; all p values < 0.001), and administration time (drug round, p = 0.023; day of the week, p = 0.024). Several interactions between these factors were also significant. Nurse experience was not significant. Higher error rates were observed for intravenous medications involving complex preparation procedures and for anti-infective drugs. Slightly lower medication error rates were observed during afternoon rounds compared to other rounds. Conclusions Potentially clinically relevant errors occurred in more than a third of all medications in this large study conducted in a resource-restricted setting. Educational interventions, focusing on intravenous medications with complex preparation procedure, particularly antibiotics, are likely to improve patient safety. PMID:26383873

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

Barcode identification for transfusion safety.

PubMed

Murphy, M F; Kay, J D S

2004-09-01

Errors related to blood transfusion in hospitals may produce catastrophic consequences. This review addresses potential solutions to prevent patient misidentification including the use of new technology, such as barcoding. A small number of studies using new technology for the transfusion process in hospitals have shown promising results in preventing errors. The studies demonstrated improved transfusion safety and staff preference for new technology such as bedside handheld scanners to carry out pretransfusion bedside checking. They also highlighted the need for considerable efforts in the training of staff in the new procedures before their successful implementation. Improvements in hospital transfusion safety are a top priority for transfusion medicine, and will depend on a combined approach including a better understanding of the causes of errors, a reduction in the complexity of routine procedures taking advantage of new technology, improved staff training, and regular monitoring of practice. The use of new technology to improve the safety of transfusion is very promising. Further development of the systems is needed to enable staff to carry out bedside transfusion procedures quickly and accurately, and to increase their functionality to justify the cost of their wider implementation.

Decreased Leftward ‘Aiming’ Motor-Intentional Spatial Cuing in Traumatic Brain Injury

PubMed Central

Wagner, Daymond; Eslinger, Paul J.; Barrett, A. M.

2016-01-01

Objective To characterize the mediation of attention and action in space following traumatic brain injury (TBI). Method Two exploratory analyses were performed to determine the influence of spatial ‘Aiming’ motor versus spatial ‘Where’ bias on line bisection in TBI participants. The first experiment compared performance according to severity and location of injury in TBI. The second experiment examined bisection performance in a larger TBI sample against a matched control group. In both experiments, participants bisected lines in near and far space using an apparatus that allowed for the fractionation of spatial Aiming versus Where error components. Results In the first experiment, participants with severe injuries tended to incur rightward error when starting from the right in far space, compared with participants with mild injuries. In the second experiment, when performance was examined at the individual level, more participants with TBI tended to incur rightward motor error compared to controls. Conclusions TBI may cause frontal-subcortical cognitive dysfunction and asymmetric motor perseveration, affecting spatial Aiming bias on line bisection. Potential effects on real-world function need further investigation. PMID:27571220

Assessment of ecologic regression in the study of lung cancer and indoor radon.

PubMed

Stidley, C A; Samet, J M

1994-02-01

Ecologic regression studies conducted to assess the cancer risk of indoor radon to the general population are subject to methodological limitations, and they have given seemingly contradictory results. The authors use simulations to examine the effects of two major methodological problems that affect these studies: measurement error and misspecification of the risk model. In a simulation study of the effect of measurement error caused by the sampling process used to estimate radon exposure for a geographic unit, both the effect of radon and the standard error of the effect estimate were underestimated, with greater bias for smaller sample sizes. In another simulation study, which addressed the consequences of uncontrolled confounding by cigarette smoking, even small negative correlations between county geometric mean annual radon exposure and the proportion of smokers resulted in negative average estimates of the radon effect. A third study considered consequences of using simple linear ecologic models when the true underlying model relation between lung cancer and radon exposure is nonlinear. These examples quantify potential biases and demonstrate the limitations of estimating risks from ecologic studies of lung cancer and indoor radon.

Dotette: Programmable, high-precision, plug-and-play droplet pipetting.

PubMed

Fan, Jinzhen; Men, Yongfan; Hao Tseng, Kuo; Ding, Yi; Ding, Yunfeng; Villarreal, Fernando; Tan, Cheemeng; Li, Baoqing; Pan, Tingrui

2018-05-01

Manual micropipettes are the most heavily used liquid handling devices in biological and chemical laboratories; however, they suffer from low precision for volumes under 1  μ l and inevitable human errors. For a manual device, the human errors introduced pose potential risks of failed experiments, inaccurate results, and financial costs. Meanwhile, low precision under 1  μ l can cause severe quantification errors and high heterogeneity of outcomes, becoming a bottleneck of reaction miniaturization for quantitative research in biochemical labs. Here, we report Dotette, a programmable, plug-and-play microfluidic pipetting device based on nanoliter liquid printing. With automated control, protocols designed on computers can be directly downloaded into Dotette, enabling programmable operation processes. Utilizing continuous nanoliter droplet dispensing, the precision of the volume control has been successfully improved from traditional 20%-50% to less than 5% in the range of 100 nl to 1000 nl. Such a highly automated, plug-and-play add-on to existing pipetting devices not only improves precise quantification in low-volume liquid handling and reduces chemical consumptions but also facilitates and automates a variety of biochemical and biological operations.

Uncertainty modelling and analysis of volume calculations based on a regular grid digital elevation model (DEM)

NASA Astrophysics Data System (ADS)

Li, Chang; Wang, Qing; Shi, Wenzhong; Zhao, Sisi

2018-05-01

The accuracy of earthwork calculations that compute terrain volume is critical to digital terrain analysis (DTA). The uncertainties in volume calculations (VCs) based on a DEM are primarily related to three factors: 1) model error (ME), which is caused by an adopted algorithm for a VC model, 2) discrete error (DE), which is usually caused by DEM resolution and terrain complexity, and 3) propagation error (PE), which is caused by the variables' error. Based on these factors, the uncertainty modelling and analysis of VCs based on a regular grid DEM are investigated in this paper. Especially, how to quantify the uncertainty of VCs is proposed by a confidence interval based on truncation error (TE). In the experiments, the trapezoidal double rule (TDR) and Simpson's double rule (SDR) were used to calculate volume, where the TE is the major ME, and six simulated regular grid DEMs with different terrain complexity and resolution (i.e. DE) were generated by a Gauss synthetic surface to easily obtain the theoretical true value and eliminate the interference of data errors. For PE, Monte-Carlo simulation techniques and spatial autocorrelation were used to represent DEM uncertainty. This study can enrich uncertainty modelling and analysis-related theories of geographic information science.

Scientific Impacts of Wind Direction Errors

NASA Technical Reports Server (NTRS)

Liu, W. Timothy; Kim, Seung-Bum; Lee, Tong; Song, Y. Tony; Tang, Wen-Qing; Atlas, Robert

2004-01-01

An assessment on the scientific impact of random errors in wind direction (less than 45 deg) retrieved from space-based observations under weak wind (less than 7 m/s ) conditions was made. averages, and these weak winds cover most of the tropical, sub-tropical, and coastal oceans. Introduction of these errors in the semi-daily winds causes, on average, 5% changes of the yearly mean Ekman and Sverdrup volume transports computed directly from the winds, respectively. These poleward movements of water are the main mechanisms to redistribute heat from the warmer tropical region to the colder high- latitude regions, and they are the major manifestations of the ocean's function in modifying Earth's climate. Simulation by an ocean general circulation model shows that the wind errors introduce a 5% error in the meridional heat transport at tropical latitudes. The simulation also shows that the erroneous winds cause a pile-up of warm surface water in the eastern tropical Pacific, similar to the conditions during El Nino episode. Similar wind directional errors cause significant change in sea-surface temperature and sea-level patterns in coastal oceans in a coastal model simulation. Previous studies have shown that assimilation of scatterometer winds improves 3-5 day weather forecasts in the Southern Hemisphere. When directional information below 7 m/s was withheld, approximately 40% of the improvement was lost

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

PubMed

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

2008-08-01

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

Human Factors Process Task Analysis: Liquid Oxygen Pump Acceptance Test Procedure at the Advanced Technology Development Center

NASA Technical Reports Server (NTRS)

Diorio, Kimberly A.; Voska, Ned (Technical Monitor)

2002-01-01

This viewgraph presentation provides information on Human Factors Process Failure Modes and Effects Analysis (HF PFMEA). HF PFMEA includes the following 10 steps: Describe mission; Define System; Identify human-machine; List human actions; Identify potential errors; Identify factors that effect error; Determine likelihood of error; Determine potential effects of errors; Evaluate risk; Generate solutions (manage error). The presentation also describes how this analysis was applied to a liquid oxygen pump acceptance test.

Causes and Remedies for Errors in International Forest Products Trade Data: Examples from the Hardwood Trade Statistics

Treesearch

William G. Luppold; William G. Luppold

1995-01-01

The quality of data concerning international hardwood products trade declined in the 1980s because of several problems associated with the collection and processing of individual export transaction records. This note examines the source, impact, and remedies for data problems caused by data screening procedures, nonreporting, recording errors, and alternative...

Analysis of medication-related malpractice claims: causes, preventability, and costs.

PubMed

Rothschild, Jeffrey M; Federico, Frank A; Gandhi, Tejal K; Kaushal, Rainu; Williams, Deborah H; Bates, David W

2002-11-25

Adverse drug events (ADEs) may lead to serious injury and may result in malpractice claims. While ADEs resulting in claims are not representative of all ADEs, such data provide a useful resource for studying ADEs. Therefore, we conducted a review of medication-related malpractice claims to study their frequency, nature, and costs and to assess the human factor failures associated with preventable ADEs. We also assessed the potential benefits of proved effective ADE prevention strategies on ADE claims prevention. We conducted a retrospective analysis of a New England malpractice insurance company claims records from January 1, 1990, to December 31, 1999. Cases were electronically screened for possible ADEs and followed up by independent review of abstracts by 2 physician reviewers (T.K.G. and R.K.). Additional in-depth claims file reviews identified potential human factor failures associated with ADEs. Adverse drug events represented 6.3% (129/2040) of claims. Adverse drug events were judged preventable in 73% (n = 94) of the cases and were nearly evenly divided between outpatient and inpatient settings. The most frequently involved medication classes were antibiotics, antidepressants or antipsychotics, cardiovascular drugs, and anticoagulants. Among these ADEs, 46% were life threatening or fatal. System deficiencies and performance errors were the most frequent cause of preventable ADEs. The mean costs of defending malpractice claims due to ADEs were comparable for nonpreventable inpatient and outpatient ADEs and preventable outpatient ADEs (mean, $64,700-74,200), but costs were considerably greater for preventable inpatient ADEs (mean, $376,500). Adverse drug events associated with malpractice claims were often severe, costly, and preventable, and about half occurred in outpatients. Many interventions could potentially have prevented ADEs, with error proofing and process standardization covering the greatest proportion of events.

Regionalized PM2.5 Community Multiscale Air Quality model performance evaluation across a continuous spatiotemporal domain.

PubMed

Reyes, Jeanette M; Xu, Yadong; Vizuete, William; Serre, Marc L

2017-01-01

The regulatory Community Multiscale Air Quality (CMAQ) model is a means to understanding the sources, concentrations and regulatory attainment of air pollutants within a model's domain. Substantial resources are allocated to the evaluation of model performance. The Regionalized Air quality Model Performance (RAMP) method introduced here explores novel ways of visualizing and evaluating CMAQ model performance and errors for daily Particulate Matter ≤ 2.5 micrometers (PM2.5) concentrations across the continental United States. The RAMP method performs a non-homogenous, non-linear, non-homoscedastic model performance evaluation at each CMAQ grid. This work demonstrates that CMAQ model performance, for a well-documented 2001 regulatory episode, is non-homogeneous across space/time. The RAMP correction of systematic errors outperforms other model evaluation methods as demonstrated by a 22.1% reduction in Mean Square Error compared to a constant domain wide correction. The RAMP method is able to accurately reproduce simulated performance with a correlation of r = 76.1%. Most of the error coming from CMAQ is random error with only a minority of error being systematic. Areas of high systematic error are collocated with areas of high random error, implying both error types originate from similar sources. Therefore, addressing underlying causes of systematic error will have the added benefit of also addressing underlying causes of random error.

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.

In vivo reproducibility of robotic probe placement for a novel ultrasound-guided radiation therapy system

PubMed Central

Lediju Bell, Muyinatu A.; Sen, H. Tutkun; Iordachita, Iulian; Kazanzides, Peter; Wong, John

2014-01-01

Abstract. Ultrasound can provide real-time image guidance of radiation therapy, but the probe-induced tissue deformations cause local deviations from the treatment plan. If placed during treatment planning, the probe causes streak artifacts in required computed tomography (CT) images. To overcome these challenges, we propose robot-assisted placement of an ultrasound probe, followed by replacement with a geometrically identical, CT-compatible model probe. In vivo reproducibility was investigated by implanting a canine prostate, liver, and pancreas with three 2.38-mm spherical markers in each organ. The real probe was placed to visualize the markers and subsequently replaced with the model probe. Each probe was automatically removed and returned to the same position or force. Under position control, the median three-dimensional reproducibility of marker positions was 0.6 to 0.7 mm, 0.3 to 0.6 mm, and 1.1 to 1.6 mm in the prostate, liver, and pancreas, respectively. Reproducibility was worse under force control. Probe substitution errors were smallest for the prostate (0.2 to 0.6 mm) and larger for the liver and pancreas (4.1 to 6.3 mm), where force control generally produced larger errors than position control. Results indicate that position control is better than force control for this application, and the robotic approach has potential, particularly for relatively constrained organs and reproducibility errors that are smaller than established treatment margins. PMID:26158038

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings.

PubMed

Hedlund, Nancy; Beer, Idal; Hoppe-Tichy, Torsten; Trbovich, Patricia

2017-12-28

To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings. Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method. Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes. The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

AICPA standard aids in detecting risk factors for fraud. American Institute of Certified Public Accountants.

PubMed

Reinstein, A; Dery, R J

1999-10-01

The American Institute of Certified Public Accountants' Statement on Auditing Standards (SAS) No. 82, Consideration of Fraud in a Financial Statement Audit, requires independent auditors to obtain reasonable assurance that financial statements are free of material mis-statements caused by error or fraud. SAS No. 82 provides guidance for independent auditors to use to help detect and document risk factors related to potential fraud. But while SAS No. 82 suggests how auditors should assess the potential for fraud, it does not expand their detection responsibility. Accordingly, financial managers should discuss thoroughly with auditors the scope and focus of an audit as a means to further their compliance efforts.

Exploring the influence of workplace supports and relationships on safe medication practice: A pilot study of Australian graduate nurses.

PubMed

Sahay, Ashlyn; Hutchinson, Marie; East, Leah

2015-05-01

Despite the growing awareness of the benefits of positive workplace climates, unsupportive and disruptive workplace behaviours are widespread in health care organisations. Recent graduate nurses, who are often new to a workplace, are particularly vulnerable in unsupportive climates, and are also recognised to be at higher risk for medication errors. Investigate the association between workplace supports and relationships and safe medication practice among graduate nurses. Exploratory study using quantitative survey with a convenience sample of 58 nursing graduates in two Australian States. Online survey focused on graduates' self-reported medication errors, safe medication practice and the nature of workplace supports and relationships. Spearman's correlations identified that unsupportive workplace relationships were inversely related to graduate nurse medication errors and erosion of safe medication practices, while supportive Nurse Unit Manager and supportive work team relationships positively influenced safe medication practice among graduates. Workplace supports and relationships are potentially both the cause and solution to graduate nurse medication errors and safe medication practices. The findings develop further understanding about the impact of unsupportive and disruptive behaviours on patient safety and draw attention to the importance of undergraduate and continuing education strategies that promote positive workplace behaviours and graduate resilience. Copyright © 2015 Elsevier Ltd. All rights reserved.

Optical storage media data integrity studies

NASA Technical Reports Server (NTRS)

Podio, Fernando L.

1994-01-01

Optical disk-based information systems are being used in private industry and many Federal Government agencies for on-line and long-term storage of large quantities of data. The storage devices that are part of these systems are designed with powerful, but not unlimited, media error correction capacities. The integrity of data stored on optical disks does not only depend on the life expectancy specifications for the medium. Different factors, including handling and storage conditions, may result in an increase of medium errors in size and frequency. Monitoring the potential data degradation is crucial, especially for long term applications. Efforts are being made by the Association for Information and Image Management Technical Committee C21, Storage Devices and Applications, to specify methods for monitoring and reporting to the user medium errors detected by the storage device while writing, reading or verifying the data stored in that medium. The Computer Systems Laboratory (CSL) of the National Institute of Standard and Technology (NIST) has a leadership role in the development of these standard techniques. In addition, CSL is researching other data integrity issues, including the investigation of error-resilient compression algorithms. NIST has conducted care and handling experiments on optical disk media with the objective of identifying possible causes of degradation. NIST work in data integrity and related standards activities is described.

Recall bias in the assessment of exposure to mobile phones.

PubMed

Vrijheid, Martine; Armstrong, Bruce K; Bédard, Daniel; Brown, Julianne; Deltour, Isabelle; Iavarone, Ivano; Krewski, Daniel; Lagorio, Susanna; Moore, Stephen; Richardson, Lesley; Giles, Graham G; McBride, Mary; Parent, Marie-Elise; Siemiatycki, Jack; Cardis, Elisabeth

2009-05-01

Most studies of mobile phone use are case-control studies that rely on participants' reports of past phone use for their exposure assessment. Differential errors in recalled phone use are a major concern in such studies. INTERPHONE, a multinational case-control study of brain tumour risk and mobile phone use, included validation studies to quantify such errors and evaluate the potential for recall bias. Mobile phone records of 212 cases and 296 controls were collected from network operators in three INTERPHONE countries over an average of 2 years, and compared with mobile phone use reported at interview. The ratio of reported to recorded phone use was analysed as measure of agreement. Mean ratios were virtually the same for cases and controls: both underestimated number of calls by a factor of 0.81 and overestimated call duration by a factor of 1.4. For cases, but not controls, ratios increased with increasing time before the interview; however, these trends were based on few subjects with long-term data. Ratios increased by level of use. Random recall errors were large. In conclusion, there was little evidence for differential recall errors overall or in recent time periods. However, apparent overestimation by cases in more distant time periods could cause positive bias in estimates of disease risk associated with mobile phone use.

Triage: an investigation of the process and potential vulnerabilities.

PubMed

Hitchcock, Maree; Gillespie, Brigid; Crilly, Julia; Chaboyer, Wendy

2014-07-01

To explore and describe the triage process in the Emergency Department to identify problems and potential vulnerabilities that may affect the triage process. Triage is the first step in the patient journey in the Emergency Department and is often the front line in reducing the potential for errors and mistakes. A fieldwork study to provide an in-depth appreciation and understanding of the triage process. Fieldwork included unstructured observer-only observation, field notes, informal and formal interviews that were conducted over the months of June, July and August 2012. Over 170 hours of observation were performed covering day, evening and night shifts, 7 days of the week. Sixty episodes of triage were observed; 31 informal interviews and 14 formal interviews were completed. Thematic analysis was used. Three themes were identified from the analysis of the data and included: 'negotiating patient flow and care delivery through the Emergency Department'; 'interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients'; and 'varying levels of competence of the triage nurse'. In these themes, vulnerabilities and problems described included over and under triage, extended time to triage assessment, triage errors, multiple patients arriving simultaneously, emergency department and hospital overcrowding. Findings suggest that vulnerabilities in the triage process may cause disruptions to patient flow and compromise care, thus potentially impacting nurses' ability to provide safe and effective care. © 2013 John Wiley & Sons Ltd.

Improving the quality of self-monitoring blood glucose measurement: a study in reducing calibration errors.

PubMed

Baum, John M; Monhaut, Nanette M; Parker, Donald R; Price, Christopher P

2006-06-01

Two independent studies reported that 16% of people who self-monitor blood glucose used incorrectly coded meters. The degree of analytical error, however, was not characterized. Our study objectives were to demonstrate that miscoding can cause analytical errors and to characterize the potential amount of bias that can occur. The impact of calibration error with three selfblood glucose monitoring systems (BGMSs), one of which has an autocoding feature, is reported. Fresh capillary fingerstick blood from 50 subjects, 18 men and 32 women ranging in age from 23 to 82 years, was used to measure glucose with three BGMSs. Two BGMSs required manual coding and were purposely miscoded using numbers different from the one recommended for the reagent lot used. Two properly coded meters of each BGMS were included to assess within-system variability. Different reagent lots were used to challenge a third system that had autocoding capability and could not be miscoded. Some within-system comparisons showed deviations of greater than +/-30% when results obtained with miscoded meters were compared with data obtained with ones programmed using the correct code number. Similar erroneous results were found when the miscoded meter results were compared with those obtained with a glucose analyzer. For some miscoded meter and test strip combinations, error grid analysis showed that 90% of results fell into zones indicating altered clinical action. Such inaccuracies were not found with the BGMS having the autocoding feature. When certain meter code number settings of two BGMSs were used in conjunction with test strips having code numbers that did not match, statistically and clinically inaccurate results were obtained. Coding errors resulted in analytical errors of greater than +/-30% (-31.6 to +60.9%). These results confirm the value of a BGMS with an automatic coding feature.

Local blur analysis and phase error correction method for fringe projection profilometry systems.

PubMed

Rao, Li; Da, Feipeng

2018-05-20

We introduce a flexible error correction method for fringe projection profilometry (FPP) systems in the presence of local blur phenomenon. Local blur caused by global light transport such as camera defocus, projector defocus, and subsurface scattering will cause significant systematic errors in FPP systems. Previous methods, which adopt high-frequency patterns to separate the direct and global components, fail when the global light phenomenon occurs locally. In this paper, the influence of local blur on phase quality is thoroughly analyzed, and a concise error correction method is proposed to compensate the phase errors. For defocus phenomenon, this method can be directly applied. With the aid of spatially varying point spread functions and local frontal plane assumption, experiments show that the proposed method can effectively alleviate the system errors and improve the final reconstruction accuracy in various scenes. For a subsurface scattering scenario, if the translucent object is dominated by multiple scattering, the proposed method can also be applied to correct systematic errors once the bidirectional scattering-surface reflectance distribution function of the object material is measured.

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

PubMed

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

2010-02-01

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

WISC-R Examiner Errors: Cause for Concern.

ERIC Educational Resources Information Center

Slate, John R.; Chick, David

1989-01-01

Clinical psychology graduate students (N=14) administered Wechsler Intelligence Scale for Children-Revised. Found numerous scoring and mechanical errors that influenced full-scale intelligence quotient scores on two-thirds of protocols. Particularly prone to error were Verbal subtests of Vocabulary, Comprehension, and Similarities. Noted specific…

Economic measurement of medical errors using a hospital claims database.

PubMed

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

2013-01-01

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

Medication errors in anesthesia: unacceptable or unavoidable?

PubMed

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

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

Managing human fallibility in critical aerospace situations

NASA Astrophysics Data System (ADS)

Tew, Larry

2014-11-01

Human fallibility is pervasive in the aerospace industry with over 50% of errors attributed to human error. Consider the benefits to any organization if those errors were significantly reduced. Aerospace manufacturing involves high value, high profile systems with significant complexity and often repetitive build, assembly, and test operations. In spite of extensive analysis, planning, training, and detailed procedures, human factors can cause unexpected errors. Handling such errors involves extensive cause and corrective action analysis and invariably schedule slips and cost growth. We will discuss success stories, including those associated with electro-optical systems, where very significant reductions in human fallibility errors were achieved after receiving adapted and specialized training. In the eyes of company and customer leadership, the steps used to achieve these results lead to in a major culture change in both the workforce and the supporting management organization. This approach has proven effective in other industries like medicine, firefighting, law enforcement, and aviation. The roadmap to success and the steps to minimize human error are known. They can be used by any organization willing to accept human fallibility and take a proactive approach to incorporate the steps needed to manage and minimize error.

Refractive errors in Aminu Kano Teaching Hospital, Kano Nigeria.

PubMed

Lawan, Abdu; Eme, Okpo

2011-12-01

The aim of the study is to retrospectively determine the pattern of refractive errors seen in the eye clinic of Aminu Kano Teaching Hospital, Kano-Nigeria from January to December, 2008. The clinic refraction register was used to retrieve the case folders of all patients refracted during the review period. Information extracted includes patient's age, sex, and types of refractive error. All patients had basic eye examination (to rule out other causes of subnormal vision) including intra ocular pressure measurement and streak retinoscopy at two third meter working distance. The final subjective refraction correction given to the patients was used to categorise the type of refractive error. Refractive errors was observed in 1584 patients and accounted for 26.9% of clinic attendance. There were more females than males (M: F=1.0: 1.2). The common types of refractive errors are presbyopia in 644 patients (40%), various types of astigmatism in 527 patients (33%), myopia in 216 patients (14%), hypermetropia in 171 patients (11%) and aphakia in 26 patients (2%). Refractive errors are common causes of presentation in the eye clinic. Identification and correction of refractive errors should be an integral part of eye care delivery.

The study of CD side to side error in line/space pattern caused by post-exposure bake effect

NASA Astrophysics Data System (ADS)

Huang, Jin; Guo, Eric; Ge, Haiming; Lu, Max; Wu, Yijun; Tian, Mingjing; Yan, Shichuan; Wang, Ran

2016-10-01

In semiconductor manufacturing, as the design rule has decreased, the ITRS roadmap requires crucial tighter critical dimension (CD) control. CD uniformity is one of the necessary parameters to assure good performance and reliable functionality of any integrated circuit (IC) [1] [2], and towards the advanced technology nodes, it is a challenge to control CD uniformity well. The study of corresponding CD Uniformity by tuning Post-Exposure bake (PEB) and develop process has some significant progress[3], but CD side to side error happening to some line/space pattern are still found in practical application, and the error has approached to over the uniformity tolerance. After details analysis, even though use several developer types, the CD side to side error has not been found significant relationship to the developing. In addition, it is impossible to correct the CD side to side error by electron beam correction as such error does not appear in all Line/Space pattern masks. In this paper the root cause of CD side to side error is analyzed and the PEB module process are optimized as a main factor for improvement of CD side to side error.

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 the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

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

PubMed

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

2007-11-01

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

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.

Syndromic surveillance for health information system failures: a feasibility study

PubMed Central

Ong, Mei-Sing; Magrabi, Farah; Coiera, Enrico

2013-01-01

Objective To explore the applicability of a syndromic surveillance method to the early detection of health information technology (HIT) system failures. Methods A syndromic surveillance system was developed to monitor a laboratory information system at a tertiary hospital. Four indices were monitored: (1) total laboratory records being created; (2) total records with missing results; (3) average serum potassium results; and (4) total duplicated tests on a patient. The goal was to detect HIT system failures causing: data loss at the record level; data loss at the field level; erroneous data; and unintended duplication of data. Time-series models of the indices were constructed, and statistical process control charts were used to detect unexpected behaviors. The ability of the models to detect HIT system failures was evaluated using simulated failures, each lasting for 24 h, with error rates ranging from 1% to 35%. Results In detecting data loss at the record level, the model achieved a sensitivity of 0.26 when the simulated error rate was 1%, while maintaining a specificity of 0.98. Detection performance improved with increasing error rates, achieving a perfect sensitivity when the error rate was 35%. In the detection of missing results, erroneous serum potassium results and unintended repetition of tests, perfect sensitivity was attained when the error rate was as small as 5%. Decreasing the error rate to 1% resulted in a drop in sensitivity to 0.65–0.85. Conclusions Syndromic surveillance methods can potentially be applied to monitor HIT systems, to facilitate the early detection of failures. PMID:23184193

In Defense of Clinical Autopsy and Its Practice in Cuba.

PubMed

Espinosa-Brito, Alfredo D; de Mendoza-Amat, José Hurtado

2017-01-01

There has been a notable decrease in the global practice of clinical autopsy; the rate has fallen to below 10%, even in high-income countries. This is attributed to several causes, including increased costs, overreliance on modern diagnostic techniques, cultural and religious factors, the emergence of new infectious diseases and negative attitudes on the part of doctors, even pathologists. Alternative methods to autopsy in postmortem studies have been developed based on imaging, endoscopy and biopsy (all quite expensive). These methods have been used in developed countries but never as effectively as the classic autopsy for identifying cause of death and potential medical errors. Although Cuba has also seen a decrease in its autopsy rates, they remain comparatively high. Between 1996 and 2015, there were 687,689 hospital deaths in Cuba and 381,193 autopsies, 55.4% of the total. These autopsies have positively affected medical care, training, research, innovation, management and society as a whole. Autopsies are an important tool in the National Health System's quest for safe, quality patient care based on the lessons learned from studying the deceased. KEYWORDS Autopsy, postmortem examination, postmortem diagnosis, quality of care, patient safety, medical error, Cuba.

Transmural Ultrasound-based Visualization of Patterns of Action Potential Wave Propagation in Cardiac Tissue

PubMed Central

Luther, Stefan; Singh, Rupinder; Gilmour, Robert F.

2010-01-01

The pattern of action potential propagation during various tachyarrhythmias is strongly suspected to be composed of multiple re-entrant waves, but has never been imaged in detail deep within myocardial tissue. An understanding of the nature and dynamics of these waves is important in the development of appropriate electrical or pharmacological treatments for these pathological conditions. We propose a new imaging modality that uses ultrasound to visualize the patterns of propagation of these waves through the mechanical deformations they induce. The new method would have the distinct advantage of being able to visualize these waves deep within cardiac tissue. In this article, we describe one step that would be necessary in this imaging process—the conversion of these deformations into the action potential induced active stresses that produced them. We demonstrate that, because the active stress induced by an action potential is, to a good approximation, only nonzero along the local fiber direction, the problem in our case is actually overdetermined, allowing us to obtain a complete solution. Use of two- rather than three-dimensional displacement data, noise in these displacements, and/or errors in the measurements of the fiber orientations all produce substantial but acceptable errors in the solution. We conclude that the reconstruction of action potential-induced active stress from the deformation it causes appears possible, and that, therefore, the path is open to the development of the new imaging modality. PMID:20499183

Symbolic Analysis of Concurrent Programs with Polymorphism

NASA Technical Reports Server (NTRS)

Rungta, Neha Shyam

2010-01-01

The current trend of multi-core and multi-processor computing is causing a paradigm shift from inherently sequential to highly concurrent and parallel applications. Certain thread interleavings, data input values, or combinations of both often cause errors in the system. Systematic verification techniques such as explicit state model checking and symbolic execution are extensively used to detect errors in such systems [7, 9]. Explicit state model checking enumerates possible thread schedules and input data values of a program in order to check for errors [3, 9]. To partially mitigate the state space explosion from data input values, symbolic execution techniques substitute data input values with symbolic values [5, 7, 6]. Explicit state model checking and symbolic execution techniques used in conjunction with exhaustive search techniques such as depth-first search are unable to detect errors in medium to large-sized concurrent programs because the number of behaviors caused by data and thread non-determinism is extremely large. We present an overview of abstraction-guided symbolic execution for concurrent programs that detects errors manifested by a combination of thread schedules and data values [8]. The technique generates a set of key program locations relevant in testing the reachability of the target locations. The symbolic execution is then guided along these locations in an attempt to generate a feasible execution path to the error state. This allows the execution to focus in parts of the behavior space more likely to contain an error.

Prevalence of amblyopia and patterns of refractive error in the amblyopic children of a tertiary eye care center of Nepal.

PubMed

Sapkota, K; Pirouzian, A; Matta, N S

2013-01-01

Refractive error is a common cause of amblyopia. To determine prevalence of amblyopia and the pattern and the types of refractive error in children with amblyopia in a tertiary eye hospital of Nepal. A retrospective chart review of children diagnosed with amblyopia in the Nepal Eye Hospital (NEH) from July 2006 to June 2011 was conducted. Children of age 13+ or who had any ocular pathology were excluded. Cycloplegic refraction and an ophthalmological examination was performed for all children. The pattern of refractive error and the association between types of refractive error and types of amblyopia were determined. Amblyopia was found in 0.7 % (440) of 62,633 children examined in NEH during this period. All the amblyopic eyes of the subjects had refractive error. Fifty-six percent (248) of the patients were male and the mean age was 7.74 ± 2.97 years. Anisometropia was the most common cause of amblyopia (p less than 0.001). One third (29 %) of the subjects had bilateral amblyopia due to high ametropia. Forty percent of eyes had severe amblyopia with visual acuity of 20/120 or worse. About twothirds (59.2 %) of the eyes had astigmatism. The prevalence of amblyopia in the Nepal Eye Hospital is 0.7%. Anisometropia is the most common cause of amblyopia. Astigmatism is the most common types of refractive error in amblyopic eyes. © NEPjOPH.

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

Katsuta, Y; Tohoku University Graduate School of Medicine, Sendal, Miyagi; Kadoya, N

Purpose: In this study, we developed a system to calculate three dimensional (3D) dose that reflects dosimetric error caused by leaf miscalibration for head and neck and prostate volumetric modulated arc therapy (VMAT) without additional treatment planning system calculation on real time. Methods: An original system called clarkson dose calculation based dosimetric error calculation to calculate dosimetric error caused by leaf miscalibration was developed by MATLAB (Math Works, Natick, MA). Our program, first, calculates point doses at isocenter for baseline and modified VMAT plan, which generated by inducing MLC errors that enlarged aperture size of 1.0 mm with clarkson dosemore » calculation. Second, error incuced 3D dose was generated with transforming TPS baseline 3D dose using calculated point doses. Results: Mean computing time was less than 5 seconds. For seven head and neck and prostate plans, between our method and TPS calculated error incuced 3D dose, the 3D gamma passing rates (0.5%/2 mm, global) are 97.6±0.6% and 98.0±0.4%. The dose percentage change with dose volume histogram parameter of mean dose on target volume were 0.1±0.5% and 0.4±0.3%, and with generalized equivalent uniform dose on target volume were −0.2±0.5% and 0.2±0.3%. Conclusion: The erroneous 3D dose calculated by our method is useful to check dosimetric error caused by leaf miscalibration before pre treatment patient QA dosimetry checks.« less

Physician Preferences to Communicate Neuropsychological Results: Comparison of Qualitative Descriptors and a Proposal to Reduce Communication Errors.

PubMed

Schoenberg, Mike R; Osborn, Katie E; Mahone, E Mark; Feigon, Maia; Roth, Robert M; Pliskin, Neil H

2017-11-08

Errors in communication are a leading cause of medical errors. A potential source of error in communicating neuropsychological results is confusion in the qualitative descriptors used to describe standardized neuropsychological data. This study sought to evaluate the extent to which medical consumers of neuropsychological assessments believed that results/findings were not clearly communicated. In addition, preference data for a variety of qualitative descriptors commonly used to communicate normative neuropsychological test scores were obtained. Preference data were obtained for five qualitative descriptor systems as part of a larger 36-item internet-based survey of physician satisfaction with neuropsychological services. A new qualitative descriptor system termed the Simplified Qualitative Classification System (Q-Simple) was proposed to reduce the potential for communication errors using seven terms: very superior, superior, high average, average, low average, borderline, and abnormal/impaired. A non-random convenience sample of 605 clinicians identified from four United States academic medical centers from January 1, 2015 through January 7, 2016 were invited to participate. A total of 182 surveys were completed. A minority of clinicians (12.5%) indicated that neuropsychological study results were not clearly communicated. When communicating neuropsychological standardized scores, the two most preferred qualitative descriptor systems were by Heaton and colleagues (26%) and a newly proposed Q-simple system (22%). Comprehensive norms for an extended Halstead-Reitan battery: Demographic corrections, research findings, and clinical applications. Odessa, TX: Psychological Assessment Resources) (26%) and the newly proposed Q-Simple system (22%). Initial findings highlight the need to improve and standardize communication of neuropsychological results. These data offer initial guidance for preferred terms to communicate test results and form a foundation for more standardized practice among neuropsychologists. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Anatomy of an incident

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

Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.

A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less

Anatomy of an incident

DOE PAGES

Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.; ...

2016-03-23

A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less

Depth-of-Interaction Compensation Using a Focused-Cut Scintillator for a Pinhole Gamma Camera.

PubMed

Alhassen, Fares; Kudrolli, Haris; Singh, Bipin; Kim, Sangtaek; Seo, Youngho; Gould, Robert G; Nagarkar, Vivek V

2011-06-01

Preclinical SPECT offers a powerful means to understand the molecular pathways of drug interactions in animal models by discovering and testing new pharmaceuticals and therapies for potential clinical applications. A combination of high spatial resolution and sensitivity are required in order to map radiotracer uptake within small animals. Pinhole collimators have been investigated, as they offer high resolution by means of image magnification. One of the limitations of pinhole geometries is that increased magnification causes some rays to travel through the detection scintillator at steep angles, introducing parallax errors due to variable depth-of-interaction in scintillator material, especially towards the edges of the detector field of view. These parallax errors ultimately limit the resolution of pinhole preclinical SPECT systems, especially for higher energy isotopes that can easily penetrate through millimeters of scintillator material. A pixellated, focused-cut (FC) scintillator, with its pixels laser-cut so that they are collinear with incoming rays, can potentially compensate for these parallax errors and thus improve the system resolution. We performed the first experimental evaluation of a newly developed focused-cut scintillator. We scanned a Tc-99m source across the field of view of pinhole gamma camera with a continuous scintillator, a conventional "straight-cut" (SC) pixellated scintillator, and a focused-cut scintillator, each coupled to an electron-multiplying charge coupled device (EMCCD) detector by a fiber-optic taper, and compared the measured full-width half-maximum (FWHM) values. We show that the FWHMs of the focused-cut scintillator projections are comparable to the FWHMs of the thinner SC scintillator, indicating the effectiveness of the focused-cut scintillator in compensating parallax errors.

Depth-of-Interaction Compensation Using a Focused-Cut Scintillator for a Pinhole Gamma Camera

PubMed Central

Alhassen, Fares; Kudrolli, Haris; Singh, Bipin; Kim, Sangtaek; Seo, Youngho; Gould, Robert G.; Nagarkar, Vivek V.

2011-01-01

Preclinical SPECT offers a powerful means to understand the molecular pathways of drug interactions in animal models by discovering and testing new pharmaceuticals and therapies for potential clinical applications. A combination of high spatial resolution and sensitivity are required in order to map radiotracer uptake within small animals. Pinhole collimators have been investigated, as they offer high resolution by means of image magnification. One of the limitations of pinhole geometries is that increased magnification causes some rays to travel through the detection scintillator at steep angles, introducing parallax errors due to variable depth-of-interaction in scintillator material, especially towards the edges of the detector field of view. These parallax errors ultimately limit the resolution of pinhole preclinical SPECT systems, especially for higher energy isotopes that can easily penetrate through millimeters of scintillator material. A pixellated, focused-cut (FC) scintillator, with its pixels laser-cut so that they are collinear with incoming rays, can potentially compensate for these parallax errors and thus improve the system resolution. We performed the first experimental evaluation of a newly developed focused-cut scintillator. We scanned a Tc-99m source across the field of view of pinhole gamma camera with a continuous scintillator, a conventional “straight-cut” (SC) pixellated scintillator, and a focused-cut scintillator, each coupled to an electron-multiplying charge coupled device (EMCCD) detector by a fiber-optic taper, and compared the measured full-width half-maximum (FWHM) values. We show that the FWHMs of the focused-cut scintillator projections are comparable to the FWHMs of the thinner SC scintillator, indicating the effectiveness of the focused-cut scintillator in compensating parallax errors. PMID:21731108

Expert Intraoperative Judgment and Decision-Making: Defining the Cognitive Competencies for Safe Laparoscopic Cholecystectomy.

PubMed

Madani, Amin; Watanabe, Yusuke; Feldman, Liane S; Vassiliou, Melina C; Barkun, Jeffrey S; Fried, Gerald M; Aggarwal, Rajesh

2015-11-01

Bile duct injuries from laparoscopic cholecystectomy remain a significant source of morbidity and are often the result of intraoperative errors in perception, judgment, and decision-making. This qualitative study aimed to define and characterize higher-order cognitive competencies required to safely perform a laparoscopic cholecystectomy. Hierarchical and cognitive task analyses for establishing a critical view of safety during laparoscopic cholecystectomy were performed using qualitative methods to map the thoughts and practices that characterize expert performance. Experts with more than 5 years of experience, and who have performed at least 100 laparoscopic cholecystectomies, participated in semi-structured interviews and field observations. Verbal data were transcribed verbatim, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 2 independent reviewers, and synthesized into a list of items. A conceptual framework was created based on 10 interviews with experts, 9 procedures, and 18 literary sources. Experts included 6 minimally invasive surgeons, 2 hepato-pancreatico-biliary surgeons, and 2 acute care general surgeons (median years in practice, 11 [range 8 to 14]). One hundred eight cognitive elements (35 [32%] related to situation awareness, 47 [44%] involving decision-making, and 26 [24%] action-oriented subtasks) and 75 potential errors were identified and categorized into 6 general themes and 14 procedural tasks. Of the 75 potential errors, root causes were mapped to errors in situation awareness (24 [32%]), decision-making (49 [65%]), or either one (61 [81%]). This study defines the competencies that are essential to establishing a critical view of safety and avoiding bile duct injuries during laparoscopic cholecystectomy. This framework may serve as the basis for instructional design, assessment tools, and quality-control metrics to prevent injuries and promote a culture of patient safety. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Human Factors Process Task Analysis Liquid Oxygen Pump Acceptance Test Procedure for the Advanced Technology Development Center

NASA Technical Reports Server (NTRS)

Diorio, Kimberly A.

2002-01-01

A process task analysis effort was undertaken by Dynacs Inc. commencing in June 2002 under contract from NASA YA-D6. Funding was provided through NASA's Ames Research Center (ARC), Code M/HQ, and Industrial Engineering and Safety (IES). The John F. Kennedy Space Center (KSC) Engineering Development Contract (EDC) Task Order was 5SMA768. The scope of the effort was to conduct a Human Factors Process Failure Modes and Effects Analysis (HF PFMEA) of a hazardous activity and provide recommendations to eliminate or reduce the effects of errors caused by human factors. The Liquid Oxygen (LOX) Pump Acceptance Test Procedure (ATP) was selected for this analysis. The HF PFMEA table (see appendix A) provides an analysis of six major categories evaluated for this study. These categories include Personnel Certification, Test Procedure Format, Test Procedure Safety Controls, Test Article Data, Instrumentation, and Voice Communication. For each specific requirement listed in appendix A, the following topics were addressed: Requirement, Potential Human Error, Performance-Shaping Factors, Potential Effects of the Error, Barriers and Controls, Risk Priority Numbers, and Recommended Actions. This report summarizes findings and gives recommendations as determined by the data contained in appendix A. It also includes a discussion of technology barriers and challenges to performing task analyses, as well as lessons learned. The HF PFMEA table in appendix A recommends the use of accepted and required safety criteria in order to reduce the risk of human error. The items with the highest risk priority numbers should receive the greatest amount of consideration. Implementation of the recommendations will result in a safer operation for all personnel.

Depth-of-Interaction Compensation Using a Focused-Cut Scintillator for a Pinhole Gamma Camera

NASA Astrophysics Data System (ADS)

Alhassen, Fares; Kudrolli, Haris; Singh, Bipin; Kim, Sangtaek; Seo, Youngho; Gould, Robert G.; Nagarkar, Vivek V.

2011-06-01

Preclinical SPECT offers a powerful means to understand the molecular pathways of drug interactions in animal models by discovering and testing new pharmaceuticals and therapies for potential clinical applications. A combination of high spatial resolution and sensitivity are required in order to map radiotracer uptake within small animals. Pinhole collimators have been investigated, as they offer high resolution by means of image magnification. One of the limitations of pinhole geometries is that increased magnification causes some rays to travel through the detection scintillator at steep angles, introducing parallax errors due to variable depth-of-interaction in scintillator material, especially towards the edges of the detector field of view. These parallax errors ultimately limit the resolution of pinhole preclinical SPECT systems, especially for higher energy isotopes that can easily penetrate through millimeters of scintillator material. A pixellated, focused-cut (FC) scintillator, with its pixels laser-cut so that they are collinear with incoming rays, can potentially compensate for these parallax errors and thus improve the system resolution. We performed the first experimental evaluation of a newly developed focused-cut scintillator. We scanned a Tc-99 m source across the field of view of pinhole gamma camera with a continuous scintillator, a conventional “straight-cut” (SC) pixellated scintillator, and a focused-cut scintillator, each coupled to an electron-multiplying charge coupled device (EMCCD) detector by a fiber-optic taper, and compared the measured full-width half-maximum (FWHM) values. We show that the FWHMs of the focused-cut scintillator projections are comparable to the FWHMs of the thinner SC scintillator, indicating the effectiveness of the focused-cut scintillator in compensating parallax errors.

Managerial process improvement: a lean approach to eliminating medication delivery.

PubMed

Hussain, Aftab; Stewart, LaShonda M; Rivers, Patrick A; Munchus, George

2015-01-01

Statistical evidence shows that medication errors are a major cause of injuries that concerns all health care oganizations. Despite all the efforts to improve the quality of care, the lack of understanding and inability of management to design a robust system that will strategically target those factors is a major cause of distress. The paper aims to discuss these issues. Achieving optimum organizational performance requires two key variables; work process factors and human performance factors. The approach is that healthcare administrators must take in account both variables in designing a strategy to reduce medication errors. However, strategies that will combat such phenomena require that managers and administrators understand the key factors that are causing medication delivery errors. The authors recommend that healthcare organizations implement the Toyota Production System (TPS) combined with human performance improvement (HPI) methodologies to eliminate medication delivery errors in hospitals. Despite all the efforts to improve the quality of care, there continues to be a lack of understanding and the ability of management to design a robust system that will strategically target those factors associated with medication errors. This paper proposes a solution to an ambiguous workflow process using the TPS combined with the HPI system.

Structured methods for identifying and correcting potential human errors in aviation operations

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

Nelson, W.R.

1997-10-01

Human errors have been identified as the source of approximately 60% of the incidents and accidents that occur in commercial aviation. It can be assumed that a very large number of human errors occur in aviation operations, even though in most cases the redundancies and diversities built into the design of aircraft systems prevent the errors from leading to serious consequences. In addition, when it is acknowledged that many system failures have their roots in human errors that occur in the design phase, it becomes apparent that the identification and elimination of potential human errors could significantly decrease the risksmore » of aviation operations. This will become even more critical during the design of advanced automation-based aircraft systems as well as next-generation systems for air traffic management. Structured methods to identify and correct potential human errors in aviation operations have been developed and are currently undergoing testing at the Idaho National Engineering and Environmental Laboratory (INEEL).« less

Transperineal prostate biopsy under magnetic resonance image guidance: a needle placement accuracy study.

PubMed

Blumenfeld, Philip; Hata, Nobuhiko; DiMaio, Simon; Zou, Kelly; Haker, Steven; Fichtinger, Gabor; Tempany, Clare M C

2007-09-01

To quantify needle placement accuracy of magnetic resonance image (MRI)-guided core needle biopsy of the prostate. A total of 10 biopsies were performed with 18-gauge (G) core biopsy needle via a percutaneous transperineal approach. Needle placement error was assessed by comparing the coordinates of preplanned targets with the needle tip measured from the intraprocedural coherent gradient echo images. The source of these errors was subsequently investigated by measuring displacement caused by needle deflection and needle susceptibility artifact shift in controlled phantom studies. Needle placement error due to misalignment of the needle template guide was also evaluated. The mean and standard deviation (SD) of errors in targeted biopsies was 6.5 +/- 3.5 mm. Phantom experiments showed significant placement error due to needle deflection with a needle with an asymmetrically beveled tip (3.2-8.7 mm depending on tissue type) but significantly smaller error with a symmetrical bevel (0.6-1.1 mm). Needle susceptibility artifacts observed a shift of 1.6 +/- 0.4 mm from the true needle axis. Misalignment of the needle template guide contributed an error of 1.5 +/- 0.3 mm. Needle placement error was clinically significant in MRI-guided biopsy for diagnosis of prostate cancer. Needle placement error due to needle deflection was the most significant cause of error, especially for needles with an asymmetrical bevel. (c) 2007 Wiley-Liss, Inc.

Radiation-induced refraction artifacts in the optical CT readout of polymer gel dosimeters

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

Campbell, Warren G.; Jirasek, Andrew, E-mail: jirasek@uvic.ca; Wells, Derek M.

2014-11-01

Purpose: The objective of this work is to demonstrate imaging artifacts that can occur during the optical computed tomography (CT) scanning of polymer gel dosimeters due to radiation-induced refractive index (RI) changes in polyacrylamide gels. Methods: A 1 L cylindrical polyacrylamide gel dosimeter was irradiated with 3 × 3 cm{sup 2} square beams of 6 MV photons. A prototype fan-beam optical CT scanner was used to image the dosimeter. Investigative optical CT scans were performed to examine two types of rayline bending: (i) bending within the plane of the fan-beam and (ii) bending out the plane of the fan-beam. Tomore » address structured errors, an iterative Savitzky–Golay (ISG) filtering routine was designed to filter 2D projections in sinogram space. For comparison, 2D projections were alternatively filtered using an adaptive-mean (AM) filter. Results: In-plane rayline bending was most notably observed in optical CT projections where rays of the fan-beam confronted a sustained dose gradient that was perpendicular to their trajectory but within the fan-beam plane. These errors caused distinct streaking artifacts in image reconstructions due to the refraction of higher intensity rays toward more opaque regions of the dosimeter. Out-of-plane rayline bending was observed in slices of the dosimeter that featured dose gradients perpendicular to the plane of the fan-beam. These errors caused widespread, severe overestimations of dose in image reconstructions due to the higher-than-actual opacity that is perceived by the scanner when light is bent off of the detector array. The ISG filtering routine outperformed AM filtering for both in-plane and out-of-plane rayline errors caused by radiation-induced RI changes. For in-plane rayline errors, streaks in an irradiated region (>7 Gy) were as high as 49% for unfiltered data, 14% for AM, and 6% for ISG. For out-of-plane rayline errors, overestimations of dose in a low-dose region (∼50 cGy) were as high as 13 Gy for unfiltered data, 10 Gy for AM, and 3.1 Gy for ISG. The ISG routine also addressed unrelated artifacts that previously needed to be manually removed in sinogram space. However, the ISG routine blurred reconstructions, causing losses in spatial resolution of ∼5 mm in the plane of the fan-beam and ∼8 mm perpendicular to the fan-beam. Conclusions: This paper reveals a new category of imaging artifacts that can affect the optical CT readout of polyacrylamide gel dosimeters. Investigative scans show that radiation-induced RI changes can cause significant rayline errors when rays confront a prolonged dose gradient that runs perpendicular to their trajectory. In fan-beam optical CT, these errors manifested in two ways: (1) distinct streaking artifacts caused by in-plane rayline bending and (2) severe overestimations of opacity caused by rays bending out of the fan-beam plane and missing the detector array. Although the ISG filtering routine mitigated these errors better than an adaptive-mean filtering routine, it caused unacceptable losses in spatial resolution.« less

Radiation-induced refraction artifacts in the optical CT readout of polymer gel dosimeters.

PubMed

Campbell, Warren G; Wells, Derek M; Jirasek, Andrew

2014-11-01

The objective of this work is to demonstrate imaging artifacts that can occur during the optical computed tomography (CT) scanning of polymer gel dosimeters due to radiation-induced refractive index (RI) changes in polyacrylamide gels. A 1 L cylindrical polyacrylamide gel dosimeter was irradiated with 3 × 3 cm(2) square beams of 6 MV photons. A prototype fan-beam optical CT scanner was used to image the dosimeter. Investigative optical CT scans were performed to examine two types of rayline bending: (i) bending within the plane of the fan-beam and (ii) bending out the plane of the fan-beam. To address structured errors, an iterative Savitzky-Golay (ISG) filtering routine was designed to filter 2D projections in sinogram space. For comparison, 2D projections were alternatively filtered using an adaptive-mean (AM) filter. In-plane rayline bending was most notably observed in optical CT projections where rays of the fan-beam confronted a sustained dose gradient that was perpendicular to their trajectory but within the fan-beam plane. These errors caused distinct streaking artifacts in image reconstructions due to the refraction of higher intensity rays toward more opaque regions of the dosimeter. Out-of-plane rayline bending was observed in slices of the dosimeter that featured dose gradients perpendicular to the plane of the fan-beam. These errors caused widespread, severe overestimations of dose in image reconstructions due to the higher-than-actual opacity that is perceived by the scanner when light is bent off of the detector array. The ISG filtering routine outperformed AM filtering for both in-plane and out-of-plane rayline errors caused by radiation-induced RI changes. For in-plane rayline errors, streaks in an irradiated region (>7 Gy) were as high as 49% for unfiltered data, 14% for AM, and 6% for ISG. For out-of-plane rayline errors, overestimations of dose in a low-dose region (∼50 cGy) were as high as 13 Gy for unfiltered data, 10 Gy for AM, and 3.1 Gy for ISG. The ISG routine also addressed unrelated artifacts that previously needed to be manually removed in sinogram space. However, the ISG routine blurred reconstructions, causing losses in spatial resolution of ∼5 mm in the plane of the fan-beam and ∼8 mm perpendicular to the fan-beam. This paper reveals a new category of imaging artifacts that can affect the optical CT readout of polyacrylamide gel dosimeters. Investigative scans show that radiation-induced RI changes can cause significant rayline errors when rays confront a prolonged dose gradient that runs perpendicular to their trajectory. In fan-beam optical CT, these errors manifested in two ways: (1) distinct streaking artifacts caused by in-plane rayline bending and (2) severe overestimations of opacity caused by rays bending out of the fan-beam plane and missing the detector array. Although the ISG filtering routine mitigated these errors better than an adaptive-mean filtering routine, it caused unacceptable losses in spatial resolution.

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.

Refinements in the short-circuit technique and its application to active potassium transport across the cecropia midgut.

PubMed

Wood, J L; Moreton, R B

1978-12-01

1. The conventional, two-electrode method for measuring potential difference across an epithelium is subject to error due to potential gradients caused by current flow in the bathing medium. Mathematical analysis shows that the error in measuring short-circuit current is proportional to the resistivity of the bathing medium and to the separation of the two recording electrodes. It is particularly serious for the insect larval midgut, where the resistivity of the medium is high, and that of the tissue is low. 2. A system has been devised, which uses a third recording electrode to monitor directly the potential gradient in the bathing medium. By suitable electrical connexions, the gradient can be automatically compensated, leaving a residual error which depends on the thickness of the tissue, but not on the electrode separation. Because the thicknesses of most epithelia are smaller than the smallest practical electrode spacing, this error is smaller than that inherent in a two-electrode system. 3. Since voltage-gradients are automatically compensated, it is possible to obtain continuous readings of potential and current. A 'voltage-clamp' circuit is described, which allows the time-course of the short-circuit current to be studied. 4.The three-electrode system has been used to study the larval midgut of Hyalophora cecropia. The average results from five experiments were: initial potential difference (open-circuit): 98+/-11 mV (S.E.M.); short-circuit current at time 60 min: 498+/-160 microA cm=2; 'steady-state' resistance at 60 min: 150+/-26 omega cm2. The current is equivalent to a net potassium transport of 18.6 mu-equiv cm-2 h-1. 5. The electrical parameters of the midgut change rapidly with time. The potential difference decays with a half-time of about 158 min, the resistance increases with a half-time of about 16 min, and the short-circuit current decays as the sum of two exponential terms, with half-times of about 16 and 158 min respectively. In addition, potential and short-circuit current show transient responses to step changes. 6. The properties of the midgut are compared with those of other transporting epithelia, and their dependence on the degree of folding of the preparation is discussed. Their time-dependence is discussed in the context of changes in potassium content of the tissue, and the implications for measurements depending on the assumption of a steady state are outlined.

Study on the refractive errors of school going children of Pokhara city in Nepal.

PubMed

Niroula, D R; Saha, C G

Refractive errors are the one of the most common visual disorders found worldwide in school going children and also it is one of the causes of blindness. It can easily be prevented, if timely proper measures are taken. In Kathmandu valley and Mechi Zone of Nepal, the distribution of refractive errors was found to be very high. No records are available from the Western part of Nepal. Considering the importance of the refractive errors the present study had been undertaken in Pokhara city. 964 subjects (474 boys, 490 girls) were selected between age groups 10 to 19 years from 6 schools representing different region of Pokhara. After Preliminary examination: on acuity of vision with Snellen's and Jaeger's charts, the subjects were referred to the Manipal Teaching Hospital, Pokhara for confirmation of the refractive errors. Sixty two schools children (6.43%), out of 964 had refractive errors. The myopia was found to be most common (4.05%). The refractive errors were found more in Private school children (9.29%) than Government school children (4.23%), which is statistically significant (P < 0.05). More boys (7.59%) were found to have suffered from refractive errors than girls (5.31%). Further, children with vegetarian diet (10.52%) had greater number of refractive errors than non-vegetarian diet children (6.17%). In the present study, percentage distribution of myopia was found to be higher (4.05%) than the hyperopia (1.24%) and astigmatism (1.14%). Interestingly, in the present study the refractive errors were found significantly higher in Private schools children than Government schools because the children who read in Private schools have higher socioeconomic status; spend more time in home work, watching Television and Computer as compared to government schools children. These near activities of the eyes causes stress on eyes of the children and might be one of the causes of developing myopia.

Effect of neoclassical toroidal viscosity on error-field penetration thresholds in tokamak plasmas.

PubMed

Cole, A J; Hegna, C C; Callen, J D

2007-08-10

A model for field-error penetration is developed that includes nonresonant as well as the usual resonant field-error effects. The nonresonant components cause a neoclassical toroidal viscous torque that keeps the plasma rotating at a rate comparable to the ion diamagnetic frequency. The new theory is used to examine resonant error-field penetration threshold scaling in Ohmic tokamak plasmas. Compared to previous theoretical results, we find the plasma is less susceptible to error-field penetration and locking, by a factor that depends on the nonresonant error-field amplitude.

Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding.

PubMed

MacKay, Mark; Anderson, Collin; Boehme, Sabrina; Cash, Jared; Zobell, Jeffery

2016-04-01

The Institute for Safe Medication Practices has stated that parenteral nutrition (PN) is considered a high-risk medication and has the potential of causing harm. Three organizations--American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society of Health-System Pharmacists, and National Advisory Group--have published guidelines for ordering, transcribing, compounding and administering PN. These national organizations have published data on compliance to the guidelines and the risk of errors. The purpose of this article is to compare total compliance with ordering, transcription, compounding, administration, and error rate with a large pediatric institution. A computerized prescriber order entry (CPOE) program was developed that incorporates dosing with soft and hard stop recommendations and simultaneously eliminating the need for paper transcription. A CPOE team prioritized and identified issues, then developed solutions and integrated innovative CPOE and automated compounding device (ACD) technologies and practice changes to minimize opportunities for medication errors in PN prescription, transcription, preparation, and administration. Thirty developmental processes were identified and integrated in the CPOE program, resulting in practices that were compliant with A.S.P.E.N. safety consensus recommendations. Data from 7 years of development and implementation were analyzed and compared with published literature comparing error, harm rates, and cost reductions to determine if our process showed lower error rates compared with national outcomes. The CPOE program developed was in total compliance with the A.S.P.E.N. guidelines for PN. The frequency of PN medication errors at our hospital over the 7 years was 230 errors/84,503 PN prescriptions, or 0.27% compared with national data that determined that 74 of 4730 (1.6%) of prescriptions over 1.5 years were associated with a medication error. Errors were categorized by steps in the PN process: prescribing, transcription, preparation, and administration. There were no transcription errors, and most (95%) errors occurred during administration. We conclude that PN practices that conferred a meaningful cost reduction and a lower error rate (2.7/1000 PN) than reported in the literature (15.6/1000 PN) were ascribed to the development and implementation of practices that conform to national PN guidelines and recommendations. Electronic ordering and compounding programs eliminated all transcription and related opportunities for errors. © 2015 American Society for Parenteral and Enteral Nutrition.

A next generation multiscale view of inborn errors of metabolism

PubMed Central

Argmann, Carmen A.; Houten, Sander M.; Zhu, Jun; Schadt, Eric E.

2015-01-01

Inborn errors of metabolism (IEM) are not unlike common diseases. They often present as a spectrum of disease phenotypes that correlates poorly with the severity of the disease-causing mutations. This greatly impacts patient care and reveals fundamental gaps in our knowledge of disease modifying biology. Systems biology approaches that integrate multi-omics data into molecular networks have significantly improved our understanding of complex diseases. Similar approaches to study IEM are rare despite their complex nature. We highlight that existing common disease-derived datasets and networks can be repurposed to generate novel mechanistic insight in IEM and potentially identify candidate modifiers. While understanding disease pathophysiology will advance the IEM field, the ultimate goal should be to understand per individual how their phenotype emerges given their primary mutation on the background of their whole genome, not unlike personalized medicine. We foresee that panomics and network strategies combined with recent experimental innovations will facilitate this. PMID:26712461

Systematic discrepancies in Monte Carlo predictions of k-ratios emitted from thin films on substrates

NASA Astrophysics Data System (ADS)

Statham, P.; Llovet, X.; Duncumb, P.

2012-03-01

We have assessed the reliability of different Monte Carlo simulation programmes using the two available Bastin-Heijligers databases of thin-film measurements by EPMA. The MC simulation programmes tested include Curgenven-Duncumb MSMC, NISTMonte, Casino and PENELOPE. Plots of the ratio of calculated to measured k-ratios ("kcalc/kmeas") against various parameters reveal error trends that are not apparent in simple error histograms. The results indicate that the MC programmes perform quite differently on the same dataset. However, they appear to show a similar pronounced trend with a "hockey stick" shape in the "kcalc/kmeas versus kmeas" plots. The most sophisticated programme PENELOPE gives the closest correspondence with experiment but still shows a tendency to underestimate experimental k-ratios by 10 % for films that are thin compared to the electron range. We have investigated potential causes for this systematic behaviour and extended the study to data not collected by Bastin and Heijligers.

Understanding Risk Tolerance and Building an Effective Safety Culture

NASA Technical Reports Server (NTRS)

Loyd, David

2018-01-01

Estimates range from 65-90 percent of catastrophic mishaps are due to human error. NASA's human factors-related mishaps causes are estimated at approximately 75 percent. As much as we'd like to error-proof our work environment, even the most automated and complex technical endeavors require human interaction... and are vulnerable to human frailty. Industry and government are focusing not only on human factors integration into hazardous work environments, but also looking for practical approaches to cultivating a strong Safety Culture that diminishes risk. Industry and government organizations have recognized the value of monitoring leading indicators to identify potential risk vulnerabilities. NASA has adapted this approach to assess risk controls associated with hazardous, critical, and complex facilities. NASA's facility risk assessments integrate commercial loss control, OSHA (Occupational Safety and Health Administration) Process Safety, API (American Petroleum Institute) Performance Indicator Standard, and NASA Operational Readiness Inspection concepts to identify risk control vulnerabilities.

Distributed control of large space antennas

NASA Technical Reports Server (NTRS)

Cameron, J. M.; Hamidi, M.; Lin, Y. H.; Wang, S. J.

1983-01-01

A systematic way to choose control design parameters and to evaluate performance for large space antennas is presented. The structural dynamics and control properties for a Hoop and Column Antenna and a Wrap-Rib Antenna are characterized. Some results of the effects of model parameter uncertainties to the stability, surface accuracy, and pointing errors are presented. Critical dynamics and control problems for these antenna configurations are identified and potential solutions are discussed. It was concluded that structural uncertainties and model error can cause serious performance deterioration and can even destabilize the controllers. For the hoop and column antenna, large hoop and long meat and the lack of stiffness between the two substructures result in low structural frequencies. Performance can be improved if this design can be strengthened. The two-site control system is more robust than either single-site control systems for the hoop and column antenna.

Entropic Barriers for Two-Dimensional Quantum Memories

NASA Astrophysics Data System (ADS)

Brown, Benjamin J.; Al-Shimary, Abbas; Pachos, Jiannis K.

2014-03-01

Comprehensive no-go theorems show that information encoded over local two-dimensional topologically ordered systems cannot support macroscopic energy barriers, and hence will not maintain stable quantum information at finite temperatures for macroscopic time scales. However, it is still well motivated to study low-dimensional quantum memories due to their experimental amenability. Here we introduce a grid of defect lines to Kitaev's quantum double model where different anyonic excitations carry different masses. This setting produces a complex energy landscape which entropically suppresses the diffusion of excitations that cause logical errors. We show numerically that entropically suppressed errors give rise to superexponential inverse temperature scaling and polynomial system size scaling for small system sizes over a low-temperature regime. Curiously, these entropic effects are not present below a certain low temperature. We show that we can vary the system to modify this bound and potentially extend the described effects to zero temperature.

Minimizing driver errors: examining factors leading to failed target tracking and detection.

DOT National Transportation Integrated Search

2013-06-01

Driving a motor vehicle is a common practice for many individuals. Although driving becomes : repetitive and a very habitual task, errors can occur that lead to accidents. One factor that can be a : cause for such errors is a lapse in attention or a ...

Human Error: The Stakes Are Raised.

ERIC Educational Resources Information Center

Greenberg, Joel

1980-01-01

Mistakes related to the operation of nuclear power plants and other technologically complex systems are discussed. Recommendations are given for decreasing the chance of human error in the operation of nuclear plants. The causes of the Three Mile Island incident are presented in terms of the human error element. (SA)

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

Schreck, S. J.; Schepers, J. G.

Continued inquiry into rotor and blade aerodynamics remains crucial for achieving accurate, reliable prediction of wind turbine power performance under yawed conditions. To exploit key advantages conferred by controlled inflow conditions, we used EU-JOULE DATA Project and UAE Phase VI experimental data to characterize rotor power production under yawed conditions. Anomalies in rotor power variation with yaw error were observed, and the underlying fluid dynamic interactions were isolated. Unlike currently recognized influences caused by angled inflow and skewed wake, which may be considered potential flow interactions, these anomalies were linked to pronounced viscous and unsteady effects.

Performance Data Errors in Air Carrier Operations: Causes and Countermeasures

NASA Technical Reports Server (NTRS)

Berman, Benjamin A.; Dismukes, R Key; Jobe, Kimberly K.

2012-01-01

Several airline accidents have occurred in recent years as the result of erroneous weight or performance data used to calculate V-speeds, flap/trim settings, required runway lengths, and/or required climb gradients. In this report we consider 4 recent studies of performance data error, report our own study of ASRS-reported incidents, and provide countermeasures that can reduce vulnerability to accidents caused by performance data errors. Performance data are generated through a lengthy process involving several employee groups and computer and/or paper-based systems. Although much of the airline indUStry 's concern has focused on errors pilots make in entering FMS data, we determined that errors occur at every stage of the process and that errors by ground personnel are probably at least as frequent and certainly as consequential as errors by pilots. Most of the errors we examined could in principle have been trapped by effective use of existing procedures or technology; however, the fact that they were not trapped anywhere indicates the need for better countermeasures. Existing procedures are often inadequately designed to mesh with the ways humans process information. Because procedures often do not take into account the ways in which information flows in actual flight ops and time pressures and interruptions experienced by pilots and ground personnel, vulnerability to error is greater. Some aspects of NextGen operations may exacerbate this vulnerability. We identify measures to reduce the number of errors and to help catch the errors that occur.

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.

Evaluation of a UMLS Auditing Process of Semantic Type Assignments

PubMed Central

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

2007-01-01

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

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.

Hypoglycemia early alarm systems based on recursive autoregressive partial least squares models.

PubMed

Bayrak, Elif Seyma; Turksoy, Kamuran; Cinar, Ali; Quinn, Lauretta; Littlejohn, Elizabeth; Rollins, Derrick

2013-01-01

Hypoglycemia caused by intensive insulin therapy is a major challenge for artificial pancreas systems. Early detection and prevention of potential hypoglycemia are essential for the acceptance of fully automated artificial pancreas systems. Many of the proposed alarm systems are based on interpretation of recent values or trends in glucose values. In the present study, subject-specific linear models are introduced to capture glucose variations and predict future blood glucose concentrations. These models can be used in early alarm systems of potential hypoglycemia. A recursive autoregressive partial least squares (RARPLS) algorithm is used to model the continuous glucose monitoring sensor data and predict future glucose concentrations for use in hypoglycemia alarm systems. The partial least squares models constructed are updated recursively at each sampling step with a moving window. An early hypoglycemia alarm algorithm using these models is proposed and evaluated. Glucose prediction models based on real-time filtered data has a root mean squared error of 7.79 and a sum of squares of glucose prediction error of 7.35% for six-step-ahead (30 min) glucose predictions. The early alarm systems based on RARPLS shows good performance. A sensitivity of 86% and a false alarm rate of 0.42 false positive/day are obtained for the early alarm system based on six-step-ahead predicted glucose values with an average early detection time of 25.25 min. The RARPLS models developed provide satisfactory glucose prediction with relatively smaller error than other proposed algorithms and are good candidates to forecast and warn about potential hypoglycemia unless preventive action is taken far in advance. © 2012 Diabetes Technology Society.

Hypoglycemia Early Alarm Systems Based on Recursive Autoregressive Partial Least Squares Models

PubMed Central

Bayrak, Elif Seyma; Turksoy, Kamuran; Cinar, Ali; Quinn, Lauretta; Littlejohn, Elizabeth; Rollins, Derrick

2013-01-01

Background Hypoglycemia caused by intensive insulin therapy is a major challenge for artificial pancreas systems. Early detection and prevention of potential hypoglycemia are essential for the acceptance of fully automated artificial pancreas systems. Many of the proposed alarm systems are based on interpretation of recent values or trends in glucose values. In the present study, subject-specific linear models are introduced to capture glucose variations and predict future blood glucose concentrations. These models can be used in early alarm systems of potential hypoglycemia. Methods A recursive autoregressive partial least squares (RARPLS) algorithm is used to model the continuous glucose monitoring sensor data and predict future glucose concentrations for use in hypoglycemia alarm systems. The partial least squares models constructed are updated recursively at each sampling step with a moving window. An early hypoglycemia alarm algorithm using these models is proposed and evaluated. Results Glucose prediction models based on real-time filtered data has a root mean squared error of 7.79 and a sum of squares of glucose prediction error of 7.35% for six-step-ahead (30 min) glucose predictions. The early alarm systems based on RARPLS shows good performance. A sensitivity of 86% and a false alarm rate of 0.42 false positive/day are obtained for the early alarm system based on six-step-ahead predicted glucose values with an average early detection time of 25.25 min. Conclusions The RARPLS models developed provide satisfactory glucose prediction with relatively smaller error than other proposed algorithms and are good candidates to forecast and warn about potential hypoglycemia unless preventive action is taken far in advance. PMID:23439179

The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking.

PubMed

Norman, Geoffrey R; Monteiro, Sandra D; Sherbino, Jonathan; Ilgen, Jonathan S; Schmidt, Henk G; Mamede, Silvia

2017-01-01

Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases. However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases. Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes. In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits?The literature suggests that both Type 1 and Type 2 processes contribute to errors. Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established. Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits.

Surface-roughness considerations for atmospheric correction of ocean color sensors. I: The Rayleigh-scattering component.

PubMed

Gordon, H R; Wang, M

1992-07-20

The first step in the coastal zone color scanner (CZCS) atmospheric-correction algorithm is the computation of the Rayleigh-scattering contribution, Lr(r), to the radiance leaving the top of the atmosphere over the ocean. In the present algorithm Lr(r), is computed by assuming that the ocean surface is flat. Computations of the radiance leaving a Rayleigh-scattering atmosphere overlying a rough Fresnel-reflecting ocean are presented to assess the radiance error caused by the flat-ocean assumption. The surface-roughness model is described in detail for both scalar and vector (including polarization) radiative transfer theory. The computations utilizing the vector theory show that the magnitude of the error significantly depends on the assumptions made in regard to the shadowing of one wave by another. In the case of the coastal zone color scanner bands, we show that for moderate solar zenith angles the error is generally below the 1 digital count level, except near the edge of the scan for high wind speeds. For larger solar zenith angles, the error is generally larger and can exceed 1 digital count at some wavelengths over the entire scan, even for light winds. The error in Lr(r) caused by ignoring surface roughness is shown to be the same order of magnitude as that caused by uncertainties of +/- 15 mb in the surface atmospheric pressure or of +/- 50 Dobson units in the ozone concentration. For future sensors, which will have greater radiometric sensitivity, the error caused by the flat-ocean assumption in the computation of Lr(r) could be as much as an order of magnitude larger than the noise-equivalent spectral radiance in certain situations.

Evaluating an educational intervention to improve the accuracy of death certification among trainees from various specialties

PubMed Central

Villar, Jesús; Pérez-Méndez, Lina

2007-01-01

Background The inaccuracy of death certification can lead to the misallocation of resources in health care programs and research. We evaluated the rate of errors in the completion of death certificates among medical residents from various specialties, before and after an educational intervention which was designed to improve the accuracy in the certification of the cause of death. Methods A 90-min seminar was delivered to seven mixed groups of medical trainees (n = 166) from several health care institutions in Spain. Physicians were asked to read and anonymously complete a same case-scenario of death certification before and after the seminar. We compared the rates of errors and the impact of the educational intervention before and after the seminar. Results A total of 332 death certificates (166 completed before and 166 completed after the intervention) were audited. Death certificates were completed with errors by 71.1% of the physicians before the educational intervention. Following the seminar, the proportion of death certificates with errors decreased to 9% (p < 0.0001). The most common error in the completion of death certificates was the listing of the mechanism of death instead of the cause of death. Before the seminar, 56.8% listed respiratory or cardiac arrest as the immediate cause of death. None of the participants listed any mechanism of death after the educational intervention (p < 0.0001). Conclusion Major errors in the completion of the correct cause of death on death certificates are common among medical residents. A simple educational intervention can dramatically improve the accuracy in the completion of death certificates by physicians. PMID:18005414

The processing course of conflicts in third-party punishment: An event-related potential study.

PubMed

Qu, Lulu; Dou, Wei; You, Cheng; Qu, Chen

2014-09-01

In social decision-making games, uninvolved third parties usually severely punish norm violators, even though the punishment is costly for them. For this irrational behavior, the conflict caused by punishment satisfaction and monetary loss is obvious. In the present study, 18 participants observed a Dictator Game and were asked about their willingness to incur some cost to change the offers by reducing the dictator's money. A response-locked event-related potential (ERP) component, the error negativity or error-related negativity (Ne/ERN), which is evoked by error or conflict, was analyzed to investigate whether a trade-off between irrational punishment and rational private benefit occurred in the brain responses of third parties. We examined the effect of the choice type ("to change the offer" or "not to change the offer") and levels of unfairness (90:10 and 70:30) on Ne/ERN amplitudes. The results indicated that there was an ERN effect for unfair offers as Ne/ERN amplitudes were more negative for not to change the offer choices than for to change the offer choices, which suggested that participants encountered more conflict when they did not change unfair offers. Furthermore, it was implied that altruistic punishment, rather than rational utilitarianism, might be the prepotent tendency for humans that is involved in the early stage of decision-making. © 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd.

Effect of Antenna Pointing Errors on SAR Imaging Considering the Change of the Point Target Location

NASA Astrophysics Data System (ADS)

Zhang, Xin; Liu, Shijie; Yu, Haifeng; Tong, Xiaohua; Huang, Guoman

2018-04-01

Towards spaceborne spotlight SAR, the antenna is regulated by the SAR system with specific regularity, so the shaking of the internal mechanism is inevitable. Moreover, external environment also has an effect on the stability of SAR platform. Both of them will cause the jitter of the SAR platform attitude. The platform attitude instability will introduce antenna pointing error on both the azimuth and range directions, and influence the acquisition of SAR original data and ultimate imaging quality. In this paper, the relations between the antenna pointing errors and the three-axis attitude errors are deduced, then the relations between spaceborne spotlight SAR imaging of the point target and antenna pointing errors are analysed based on the paired echo theory, meanwhile, the change of the azimuth antenna gain is considered as the spotlight SAR platform moves ahead. The simulation experiments manifest the effects on spotlight SAR imaging caused by antenna pointing errors are related to the target location, that is, the pointing errors of the antenna beam will severely influence the area far away from the scene centre of azimuth direction in the illuminated scene.

Managing Errors to Reduce Accidents in High Consequence Networked Information Systems

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

Ganter, J.H.

1999-02-01

Computers have always helped to amplify and propagate errors made by people. The emergence of Networked Information Systems (NISs), which allow people and systems to quickly interact worldwide, has made understanding and minimizing human error more critical. This paper applies concepts from system safety to analyze how hazards (from hackers to power disruptions) penetrate NIS defenses (e.g., firewalls and operating systems) to cause accidents. Such events usually result from both active, easily identified failures and more subtle latent conditions that have resided in the system for long periods. Both active failures and latent conditions result from human errors. We classifymore » these into several types (slips, lapses, mistakes, etc.) and provide NIS examples of how they occur. Next we examine error minimization throughout the NIS lifecycle, from design through operation to reengineering. At each stage, steps can be taken to minimize the occurrence and effects of human errors. These include defensive design philosophies, architectural patterns to guide developers, and collaborative design that incorporates operational experiences and surprises into design efforts. We conclude by looking at three aspects of NISs that will cause continuing challenges in error and accident management: immaturity of the industry, limited risk perception, and resource tradeoffs.« less

Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint

PubMed Central

Gorgich, Enam Alhagh Charkhat; Barfroshan, Sanam; Ghoreishi, Gholamreza; Yaghoobi, Maryam

2016-01-01

Introduction and Aim: Medication errors as a serious problem in world and one of the most common medical errors that threaten patient safety and may lead to even death of them. The purpose of this study was to investigate the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Materials & Methods: This cross-sectional descriptive study was conducted on 327 nursing staff of khatam-al-anbia hospital and 62 intern nursing students in nursing and midwifery school of Zahedan, Iran, enrolled through the availability sampling in 2015. The data were collected by the valid and reliable questionnaire. To analyze the data, descriptive statistics, T-test and ANOVA were applied by use of SPSS16 software. Findings: The results showed that the most common causes of medications errors in nursing were tiredness due increased workload (97.8%), and in nursing students were drug calculation, (77.4%). The most important way for prevention in nurses and nursing student opinion, was reducing the work pressure by increasing the personnel, proportional to the number and condition of patients and also creating a unit as medication calculation. Also there was a significant relationship between the type of ward and the mean of medication errors in two groups. Conclusion: Based on the results it is recommended that nurse-managers resolve the human resources problem, provide workshops and in-service education about preparing medications, side-effects of drugs and pharmacological knowledge. Using electronic medications cards is a measure which reduces medications errors. PMID:27045413

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.

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.

A simple model for studying rotation errors of gimbal mount axes in laser tracking system based on spherical mirror as a reflection unit

NASA Astrophysics Data System (ADS)

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

2018-01-01

This paper presents a novel experimental approach and a simple model for verifying that spherical mirror of laser tracking system could lessen the effect of rotation errors of gimbal mount axes based on relative motion thinking. Enough material and evidence are provided to support that this simple model could replace complex optical system in laser tracking system. This experimental approach and model interchange the kinematic relationship between spherical mirror and gimbal mount axes in laser tracking system. Being fixed stably, gimbal mount axes' rotation error motions are replaced by spatial micro-displacements of spherical mirror. These motions are simulated by driving spherical mirror along the optical axis and vertical direction with the use of precision positioning platform. The effect on the laser ranging measurement accuracy of displacement caused by the rotation errors of gimbal mount axes could be recorded according to the outcome of laser interferometer. The experimental results show that laser ranging measurement error caused by the rotation errors is less than 0.1 μm if radial error motion and axial error motion are under 10 μm. The method based on relative motion thinking not only simplifies the experimental procedure but also achieves that spherical mirror owns the ability to reduce the effect of rotation errors of gimbal mount axes in laser tracking system.

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…

Results from a Sting Whip Correction Verification Test at the Langley 16-Foot Transonic Tunnel

NASA Technical Reports Server (NTRS)

Crawford, B. L.; Finley, T. D.

2002-01-01

In recent years, great strides have been made toward correcting the largest error in inertial Angle of Attack (AoA) measurements in wind tunnel models. This error source is commonly referred to as 'sting whip' and is caused by aerodynamically induced forces imparting dynamics on sting-mounted models. These aerodynamic forces cause the model to whip through an arc section in the pitch and/or yaw planes, thus generating a centrifugal acceleration and creating a bias error in the AoA measurement. It has been shown that, under certain conditions, this induced AoA error can be greater than one third of a degree. An error of this magnitude far exceeds the target AoA goal of 0.01 deg established at NASA Langley Research Center (LaRC) and elsewhere. New sting whip correction techniques being developed at LaRC are able to measure and reduce this sting whip error by an order of magnitude. With this increase of accuracy, the 0.01 deg AoA target is achievable under all but the most severe conditions.

Fixing Stellarator Magnetic Surfaces

NASA Astrophysics Data System (ADS)

Hanson, James D.

1999-11-01

Magnetic surfaces are a perennial issue for stellarators. The design heuristic of finding a magnetic field with zero perpendicular component on a specified outer surface often yields inner magnetic surfaces with very small resonant islands. However, magnetic fields in the laboratory are not design fields. Island-causing errors can arise from coil placement errors, stray external fields, and design inadequacies such as ignoring coil leads and incomplete characterization of current distributions within the coil pack. The problem addressed is how to eliminate such error-caused islands. I take a perturbation approach, where the zero order field is assumed to have good magnetic surfaces, and comes from a VMEC equilibrium. The perturbation field consists of error and correction pieces. The error correction method is to determine the correction field so that the sum of the error and correction fields gives zero island size at specified rational surfaces. It is particularly important to correctly calculate the island size for a given perturbation field. The method works well with many correction knobs, and a Singular Value Decomposition (SVD) technique is used to determine minimal corrections necessary to eliminate islands.

A preliminary estimate of geoid-induced variations in repeat orbit satellite altimeter observations

NASA Technical Reports Server (NTRS)

Brenner, Anita C.; Beckley, B. D.; Koblinsky, C. J.

1990-01-01

Altimeter satellites are often maintained in a repeating orbit to facilitate the separation of sea-height variations from the geoid. However, atmospheric drag and solar radiation pressure cause a satellite orbit to drift. For Geosat this drift causes the ground track to vary by + or - 1 km about the nominal repeat path. This misalignment leads to an error in the estimates of sea surface height variations because of the local slope in the geoid. This error has been estimated globally for the Geosat Exact Repeat Mission using a mean sea surface constructed from Geos 3 and Seasat altimeter data. Over most of the ocean the geoid gradient is small, and the repeat-track misalignment leads to errors of only 1 to 2 cm. However, in the vicinity of trenches, continental shelves, islands, and seamounts, errors can exceed 20 cm. The estimated error is compared with direct estimates from Geosat altimetry, and a strong correlation is found in the vicinity of the Tonga and Aleutian trenches. This correlation increases as the orbit error is reduced because of the increased signal-to-noise ratio.

Apollo 15 mission report: Apollo 15 guidance, navigation, and control system performance analysis report (supplement 1)

NASA Technical Reports Server (NTRS)

1972-01-01

This report contains the results of additional studies which were conducted to confirm the conclusions of the MSC Mission Report and contains analyses which were not completed in time to meet the mission report deadline. The LM IMU data were examined during the lunar descent and ascent phases. Most of the PGNCS descent absolute velocity error was caused by platform misalignments. PGNCS radial velocity divergence from AGS during the early part of descent was partially caused by PGNCS gravity computation differences from AGS. The remainder of the differences between PGNCS and AGS velocity were easily attributable to attitude reference alignment differences and tolerable instrument errors. For ascent the PGNCS radial velocity error at insertion was examined. The total error of 10.8 ft/sec was well within mission constraints but larger than expected. Of the total error, 2.30 ft/sec was PIPA bias error, which was suspected to exist pre-lunar liftoff. The remaining 8.5 ft/sec is most probably satisified with a large pre-liftoff planform misalignment.

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.

Causes of the sharp increase in the time series of surface solar radiation in China between 1990 and 1993

NASA Astrophysics Data System (ADS)

Wang, Yawen; Wild, Martin

2017-02-01

During 1990-1993, a nation-wide replacement of the instruments measuring surface solar radiation (SSR) and a restructuring of SSR stations took place in China. Meanwhile, a sudden upward jump was noted in published composite time series of observed SSR records in this period. This study clarifies that about 1/3 of the magnitude of the SSR jump in China was accidentally caused by the abandonment/establishment of 51 stations (˜39% of total) during the period of 1990-1993. The remaining 2/3 of the SSR jump was only caused by 22 stations detected by the methods of the accumulated deviation curve and the Mann-Whitney U test. Out of these 22 stations, about 1/4 of the SSR jump were caused by 6 stations due to natural factors, as similar variations were recorded by sunshine duration. The other 3/4 were caused by the remaining 16 stations as a result of artificial factors such as instrument replacement, changes in the classification or location of stations, or potential operational errors.

Analysis of phase error effects in multishot diffusion-prepared turbo spin echo imaging

PubMed Central

Cervantes, Barbara; Kooijman, Hendrik; Karampinos, Dimitrios C.

2017-01-01

Background To characterize the effect of phase errors on the magnitude and the phase of the diffusion-weighted (DW) signal acquired with diffusion-prepared turbo spin echo (dprep-TSE) sequences. Methods Motion and eddy currents were identified as the main sources of phase errors. An analytical expression for the effect of phase errors on the acquired signal was derived and verified using Bloch simulations, phantom, and in vivo experiments. Results Simulations and experiments showed that phase errors during the diffusion preparation cause both magnitude and phase modulation on the acquired data. When motion-induced phase error (MiPe) is accounted for (e.g., with motion-compensated diffusion encoding), the signal magnitude modulation due to the leftover eddy-current-induced phase error cannot be eliminated by the conventional phase cycling and sum-of-squares (SOS) method. By employing magnitude stabilizers, the phase-error-induced magnitude modulation, regardless of its cause, was removed but the phase modulation remained. The in vivo comparison between pulsed gradient and flow-compensated diffusion preparations showed that MiPe needed to be addressed in multi-shot dprep-TSE acquisitions employing magnitude stabilizers. Conclusions A comprehensive analysis of phase errors in dprep-TSE sequences showed that magnitude stabilizers are mandatory in removing the phase error induced magnitude modulation. Additionally, when multi-shot dprep-TSE is employed the inconsistent signal phase modulation across shots has to be resolved before shot-combination is performed. PMID:28516049

Effect of photogrammetric reading error on slope-frequency distributions. [obtained from Apollo 17 mission

NASA Technical Reports Server (NTRS)

Moore, H. J.; Wu, S. C.

1973-01-01

The effect of reading error on two hypothetical slope frequency distributions and two slope frequency distributions from actual lunar data in order to ensure that these errors do not cause excessive overestimates of algebraic standard deviations for the slope frequency distributions. The errors introduced are insignificant when the reading error is small and the slope length is large. A method for correcting the errors in slope frequency distributions is presented and applied to 11 distributions obtained from Apollo 15, 16, and 17 panoramic camera photographs and Apollo 16 metric camera photographs.

Canceling the momentum in a phase-shifting algorithm to eliminate spatially uniform errors.

PubMed

Hibino, Kenichi; Kim, Yangjin

2016-08-10

In phase-shifting interferometry, phase modulation nonlinearity causes both spatially uniform and nonuniform errors in the measured phase. Conventional linear-detuning error-compensating algorithms only eliminate the spatially variable error component. The uniform error is proportional to the inertial momentum of the data-sampling weight of a phase-shifting algorithm. This paper proposes a design approach to cancel the momentum by using characteristic polynomials in the Z-transform space and shows that an arbitrary M-frame algorithm can be modified to a new (M+2)-frame algorithm that acquires new symmetry to eliminate the uniform error.

High-Accuracy, Compact Scanning Method and Circuit for Resistive Sensor Arrays.

PubMed

Kim, Jong-Seok; Kwon, Dae-Yong; Choi, Byong-Deok

2016-01-26

The zero-potential scanning circuit is widely used as read-out circuit for resistive sensor arrays because it removes a well known problem: crosstalk current. The zero-potential scanning circuit can be divided into two groups based on type of row drivers. One type is a row driver using digital buffers. It can be easily implemented because of its simple structure, but we found that it can cause a large read-out error which originates from on-resistance of the digital buffers used in the row driver. The other type is a row driver composed of operational amplifiers. It, very accurately, reads the sensor resistance, but it uses a large number of operational amplifiers to drive rows of the sensor array; therefore, it severely increases the power consumption, cost, and system complexity. To resolve the inaccuracy or high complexity problems founded in those previous circuits, we propose a new row driver which uses only one operational amplifier to drive all rows of a sensor array with high accuracy. The measurement results with the proposed circuit to drive a 4 × 4 resistor array show that the maximum error is only 0.1% which is remarkably reduced from 30.7% of the previous counterpart.

Multiple Intravenous Infusions Phase 1b

PubMed Central

Cassano-Piché, A; Fan, M; Sabovitch, S; Masino, C; Easty, AC

2012-01-01

Background Minimal research has been conducted into the potential patient safety issues related to administering multiple intravenous (IV) infusions to a single patient. Previous research has highlighted that there are a number of related safety risks. In Phase 1a of this study, an analysis of 2 national incident-reporting databases (Institute for Safe Medical Practices Canada and United States Food and Drug Administration MAUDE) found that a high percentage of incidents associated with the administration of multiple IV infusions resulted in patient harm. Objectives The primary objectives of Phase 1b of this study were to identify safety issues with the potential to cause patient harm stemming from the administration of multiple IV infusions; and to identify how nurses are being educated on key principles required to safely administer multiple IV infusions. Data Sources and Review Methods A field study was conducted at 12 hospital clinical units (sites) across Ontario, and telephone interviews were conducted with program coordinators or instructors from both the Ontario baccalaureate nursing degree programs and the Ontario postgraduate Critical Care Nursing Certificate programs. Data were analyzed using Rasmussen’s 1997 Risk Management Framework and a Health Care Failure Modes and Effects Analysis. Results Twenty-two primary patient safety issues were identified with the potential to directly cause patient harm. Seventeen of these (critical issues) were categorized into 6 themes. A cause-consequence tree was established to outline all possible contributing factors for each critical issue. Clinical recommendations were identified for immediate distribution to, and implementation by, Ontario hospitals. Future investigation efforts were planned for Phase 2 of the study. Limitations This exploratory field study identifies the potential for errors, but does not describe the direct observation of such errors, except in a few cases where errors were observed. Not all issues are known in advance, and the frequency of errors is too low to be observed in the time allotted and with the limited sample of observations. Conclusions The administration of multiple IV infusions to a single patient is a complex task with many potential associated patient safety risks. Improvements to infusion and infusion-related technology, education standards, clinical best practice guidelines, hospital policies, and unit work practices are required to reduce the risk potential. This report makes several recommendations to Ontario hospitals so that they can develop an awareness of the issues highlighted in this report and minimize some of the risks. Further investigation of mitigating strategies is required and will be undertaken in Phase 2 of this research. Plain Language Summary Patients, particularly in critical care environments, often require multiple intravenous (IV) medications via large volumetric or syringe infusion pumps. The infusion of multiple IV medications is not without risk; unintended errors during these complex procedures have resulted in patient harm. However, the range of associated risks and the factors contributing to these risks are not well understood. Health Quality Ontario’s Ontario Health Technology Advisory Committee commissioned the Health Technology Safety Research Team at the University Health Network to conduct a multi-phase study to identify and mitigate the risks associated with multiple IV infusions. Some of the questions addressed by the team were as follows: What is needed to reduce the risk of errors for individuals who are receiving a lot of medications? What strategies work best? The initial report, Multiple Intravenous Infusions Phase 1a: Situation Scan Summary Report, summarizes the interim findings based on a literature review, an incident database review, and a technology scan. The Health Technology Safety Research Team worked in close collaboration with the Institute for Safe Medication Practices Canada on an exploratory study to understand the risks associated with multiple IV infusions and the degree to which nurses are educated to help mitigate them. The current report, Multiple Intravenous Infusions Phase 1b: Practice and Training Scan, presents the findings of a field study of 12 hospital clinical units across Ontario, as well as 13 interviews with educators from baccalaureate-level nursing degree programs and postgraduate Critical Care Nursing Certificate programs. It makes 9 recommendations that emphasize best practices for the administration of multiple IV infusions and pertain to secondary infusions, line identification, line set-up and removal, and administering IV bolus medications. The Health Technology Safety Research Team has also produced an associated report for hospitals entitled Mitigating the Risks Associated With Multiple IV Infusions: Recommendations Based on a Field Study of Twelve Ontario Hospitals, which highlights the 9 interim recommendations and provides a brief rationale for each one. PMID:23074426

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

PubMed

Hicks, Rodney W; Becker, Shawn C

2006-01-01

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

A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change.

PubMed

Clifford, Sean Patrick; Mick, Paul Brian; Derhake, Brian Matthew

2016-01-01

A 28-year-old man presented emergently to the operating room following a gun-shot injury to his right groin. Our hospital's Massive Transfusion Protocol was initiated as the patient entered the operating room actively hemorrhaging and severely hypotensive. During the aggressive resuscitation efforts, the patient was inadvertently transfused 2 units of packed red blood cells intended for another patient due to a series of errors. Fortunately, the incorrect product was compatible, and the patient recovered from his near-fatal injuries. Root cause analysis was used to review the transfusion error and develop an action plan to help prevent future occurrences.

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

Barbee, D; McCarthy, A; Galavis, P

Purpose: Errors found during initial physics plan checks frequently require replanning and reprinting, resulting decreased departmental efficiency. Additionally, errors may be missed during physics checks, resulting in potential treatment errors or interruption. This work presents a process control created using the Eclipse Scripting API (ESAPI) enabling dosimetrists and physicists to detect potential errors in the Eclipse treatment planning system prior to performing any plan approvals or printing. Methods: Potential failure modes for five categories were generated based on available ESAPI (v11) patient object properties: Images, Contours, Plans, Beams, and Dose. An Eclipse script plugin (PlanCheck) was written in C# tomore » check errors most frequently observed clinically in each of the categories. The PlanCheck algorithms were devised to check technical aspects of plans, such as deliverability (e.g. minimum EDW MUs), in addition to ensuring that policy and procedures relating to planning were being followed. The effect on clinical workflow efficiency was measured by tracking the plan document error rate and plan revision/retirement rates in the Aria database over monthly intervals. Results: The number of potential failure modes the PlanCheck script is currently capable of checking for in the following categories: Images (6), Contours (7), Plans (8), Beams (17), and Dose (4). Prior to implementation of the PlanCheck plugin, the observed error rates in errored plan documents and revised/retired plans in the Aria database was 20% and 22%, respectively. Error rates were seen to decrease gradually over time as adoption of the script improved. Conclusion: A process control created using the Eclipse scripting API enabled plan checks to occur within the planning system, resulting in reduction in error rates and improved efficiency. Future work includes: initiating full FMEA for planning workflow, extending categories to include additional checks outside of ESAPI via Aria database queries, and eventual automated plan checks.« less

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

ERIC Educational Resources Information Center

Vocat, Roland; Pourtois, Gilles; Vuilleumier, Patrik

2011-01-01

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

TRAINING ERRORS AND RUNNING RELATED INJURIES: A SYSTEMATIC REVIEW

PubMed Central

Buist, Ida; Sørensen, Henrik; Lind, Martin; Rasmussen, Sten

2012-01-01

Purpose: The purpose of this systematic review was to examine the link between training characteristics (volume, duration, frequency, and intensity) and running related injuries. Methods: A systematic search was performed in PubMed, Web of Science, Embase, and SportDiscus. Studies were included if they examined novice, recreational, or elite runners between the ages of 18 and 65. Exposure variables were training characteristics defined as volume, distance or mileage, time or duration, frequency, intensity, speed or pace, or similar terms. The outcome of interest was Running Related Injuries (RRI) in general or specific RRI in the lower extremity or lower back. Methodological quality was evaluated using quality assessment tools of 11 to 16 items. Results: After examining 4561 titles and abstracts, 63 articles were identified as potentially relevant. Finally, nine retrospective cohort studies, 13 prospective cohort studies, six case-control studies, and three randomized controlled trials were included. The mean quality score was 44.1%. Conflicting results were reported on the relationships between volume, duration, intensity, and frequency and RRI. Conclusion: It was not possible to identify which training errors were related to running related injuries. Still, well supported data on which training errors relate to or cause running related injuries is highly important for determining proper prevention strategies. If methodological limitations in measuring training variables can be resolved, more work can be conducted to define training and the interactions between different training variables, create several hypotheses, test the hypotheses in a large scale prospective study, and explore cause and effect relationships in randomized controlled trials. Level of evidence: 2a PMID:22389869

Internal Medicine Trainees’ Views of Training Adequacy and Duty Hours Restrictions in 2009

PubMed Central

Shea, Judy A.; Weissman, Arlene; McKinney, Sean; Silber, Jeffrey H.; Volpp, Kevin G.

2012-01-01

Purpose To gauge internal medicine (IM) trainees’ perceptions regarding aspects of their inpatient rotations, including supervision and educational opportunities, the perceived effect of duty hours regulations on quality of patient care, the causes of medical errors, and sleep. Method The authors analyzed the results of questionnaires administered to trainees following the October 2009 IM In-Training Examination (IM-ITE). Results Of the 21,768 IM trainees in post-graduate years 1 through 3 who took the IM-ITE, 18,272 (83.9%) responded. The majority of these trainees (87.7%) reported that supervision was adequate, and nearly half (46.3%) reported insufficient or minimal time to participate in learning activities. Two-thirds or more of medicine trainees thought specific work regulations such as limited shift length and more time off after nights and extended shifts would at least “occasionally,” if not “usually” or “always,” improve patient care. IM trainees at least “occasionally” attributed errors to workload (68.8% of respondents), fatigue (66.9%), inexperience or lack of knowledge (61.0%), incomplete handoffs (60.2%), and insufficient ancillary staff (53.5%). IM trainees’ sleep hours were limited during extended and overnight shifts. Conclusions IM trainees agree that limited educational opportunities are the weakest part of the average inpatient rotation. Few have complaints about the adequacy of supervision. These trainees’ optimism regarding the positive influence of potential work-hour restrictions on patient care and their views of likely causes of medical errors suggest the need for innovative patient care schedules and education curricula. PMID:22622211

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

PubMed Central

Aljasmi, Fatema; Almalood, Fatema

2018-01-01

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

Motoneuron axon pathfinding errors in zebrafish: Differential effects related to concentration and timing of nicotine exposure

PubMed Central

Menelaou, Evdokia; Paul, Latoya T.; Perera, Surangi N.; Svoboda, Kurt R.

2015-01-01

Nicotine exposure during embryonic stages of development can affect many neurodevelopmental processes. In the developing zebrafish, exposure to nicotine was reported to cause axonal pathfinding errors in the later born secondary motoneurons (SMN). These alterations in SMN axon morphology coincided with muscle degeneration at high nicotine concentrations (15–30µM). Previous work showed that the paralytic mutant zebrafish known as sofa potato, exhibited nicotine-induced effects onto SMN axons at these high concentrations but in the absence of any muscle deficits, indicating that pathfinding errors could occur independent of muscle effects. In this study, we used varying concentrations of nicotine at different developmental windows of exposure to specifically isolate its effects onto subpopulations of motoneuron axons. We found that nicotine exposure can affect SMN axon morphology in a dose-dependent manner. At low concentrations of nicotine, SMN axons exhibited pathfinding errors, in the absence of any nicotine-induced muscle abnormalities. Moreover, the nicotine exposure paradigms used affected the 3 subpopulations of SMN axons differently, but the dorsal projecting SMN axons were primarily affected. We then identified morphologically distinct pathfinding errors that best described the nicotine-induced effects on dorsal projecting SMN axons. To test whether SMN pathfinding was potentially influenced by alterations in the early born primary motoneuron (PMN), we performed dual labeling studies, where both PMN and SMN axons were simultaneously labeled with antibodies. We show that only a subset of the SMN axon pathfinding errors coincided with abnormal PMN axonal targeting in nicotine-exposed zebrafish. We conclude that nicotine exposure can exert differential effects depending on the levels of nicotine and developmental exposure window. PMID:25668718

[Communication of scientific fraud].

PubMed

Zeitoun, Jean-David; Rouquette, Sébastien

2012-09-01

There is for a scientific journal several levels of communication depending of the degree of suspicion or certainty of a case of error or fraud. The task is increasingly difficult for journal editors as disclosed cases of fraud are more common and scientific communication on this topic is growing. Biomedical fraud is fairly little reported by the mainstream press and causes of this low interest are not currently well understood. The difficulty of processing this type of news for journalists appears to be one possible reason. The potentially numerous and significant consequences of fraud on health professionals are poorly documented. Though it is likely to cause a feeling of distrust and create controversy, the impact of fraud on the general public is poorly studied and appears multifactorial. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Reflection of medical error highlighted on media in Turkey: A retrospective study

PubMed Central

Isik, Oguz; Bayin, Gamze; Ugurluoglu, Ozgur

2016-01-01

Objective: This study was performed with the aim of identifying how news on medical errors have be transmitted, and how the types, reasons, and conclusions of medical errors have been reflected to by the media in Turkey. Methods: A content analysis method was used in the study, and in this context, the data for the study was acquired by scanning five newspapers with the top editions on the national basis between the years 2012 and 2015 for the news about medical errors. Some specific selection criteria was used for the scanning of resulted news, and 116 news items acquired as a result of all the eliminations. Results: According to the results of the study; the vast majority of medical errors (40.5%) transmitted by the news resulted from the negligence of the medical staff. The medical errors were caused by physicians in the ratio of 74.1%, they most commonly occurred in state hospitals (31.9%). Another important result of the research was that medical errors resulted in either patient death to a large extent (51.7%), or permanent damage and disability to patients (25.0%). Conclusion: The news concerning medical errors provided information about the types, causes, and the results of these medical errors. It also reflected the media point of view on the issue. The examination of the content of the medical errors reported by the media were important which calls for appropriate interventions to avoid and minimize the occurrence of medical errors by improving the healthcare delivery system. PMID:27882026

A survey of the prevalence of refractive errors among children in lower primary schools in Kampala district.

PubMed

Kawuma, Medi; Mayeku, Robert

2002-08-01

Refractive errors are a known cause of visual impairment and may cause blindness worldwide. In children, refractive errors may prevent those afflicted from progressing with their studies. In Uganda, like in many developing countries, there is no established vision-screening programme for children on commencement of school, such that those with early onset of such errors will have many years of poor vision. Over all, there is limited information on refractive errors among children in Africa. To determine the prevalence of refractive errors among school children attending lower primary in Kampala district; the frequency of the various types of refractive errors, and their relationship to sexuality and ethnicity. A cross-sectional descriptive study. Kampala district, Uganda A total of 623 children aged between 6 and 9 years had a visual acuity testing done at school using the same protocol; of these 301 (48.3%) were boys and 322 (51.7%) girls. Seventy-three children had a significant refractive error of +/-0.50 or worse in one or both eyes, giving a prevalence of 11.6% and the commonest single refractive error was astigmatism, which accounted for 52% of all errors. This was followed by hypermetropia, and myopia was the least common. Significant refractive errors occur among primary school children aged 6 to 9 years at a prevalence of approximately 12%. Therefore, there is a need to have regular and simple vision testing in primary school children at least at the commencement of school so as to defect those who may suffer from these disabilities.

Improving UK Air Quality Modelling Through Exploitation of Satellite Observations

NASA Astrophysics Data System (ADS)

Pope, Richard; Chipperfield, Martyn; Savage, Nick

2014-05-01

In this work the applicability of satellite observations to evaluate the operational UK Met Office Air Quality in the Unified Model (AQUM) have been investigated. The main focus involved the AQUM validation against satellite observations, investigation of satellite retrieval error types and of synoptic meteorological-atmospheric chemistry relationships simulated/seen by the AQUM/satellite. The AQUM is a short range forecast model of atmospheric chemistry and aerosols up to 5 days. It has been designed to predict potentially hazardous air pollution events, e.g. high concentrations of surface ozone. The AQUM has only been validated against UK atmospheric chemistry recording surface stations. Therefore, satellite observations of atmospheric chemistry have been used to further validate the model, taking advantage of better satellite spatial coverage. Observations of summer and winter 2006 tropospheric column NO2 from both OMI and SCIAMACHY show that the AQUM generally compares well with the observations. However, in northern England positive biases (AQUM - satellite) suggest that the AQUM overestimates column NO2; we present results of sensitivity experiments on UK emissions datasets suspected to be the cause. In winter, the AQUM over predicts background column NO2 when compared to both satellite instruments. We hypothesise that the cause is the AQUM winter night-time chemistry, where the NO2 sinks are not substantially defined. Satellite data are prone to errors/uncertainty such as random, systematic and smoothing errors. We have investigated these error types and developed an algorithm to calculate and reduce the random error component of DOAS NO2 retrievals, giving more robust seasonal satellite composites. The Lamb Weather Types (LWT), an objective method of classifying the daily synoptic weather over the UK, were used to create composite satellite maps of column NO2 under different synoptic conditions. Under cyclonic conditions, satellite observed UK column NO2 is reduced as the indicative south-westerly flow transports it away from the UK over the North Sea. However, under anticyclonic conditions, the satellite shows that the stable conditions enhance the build-up of column NO2 over source regions. The influence of wind direction on column NO2 can also be seen from space with transport leeward of the source regions.

The effect of sediment loading in Fennoscandia and the Barents Sea during the last glacial cycle on glacial isostatic adjustment observations

NASA Astrophysics Data System (ADS)

van der Wal, Wouter; IJpelaar, Thijs

2017-09-01

Models for glacial isostatic adjustment (GIA) routinely include the effects of meltwater redistribution and changes in topography and coastlines. Since the sediment transport related to the dynamics of ice sheets may be comparable to that of sea level rise in terms of surface pressure, the loading effect of sediment deposition could cause measurable ongoing viscous readjustment. Here, we study the loading effect of glacially induced sediment redistribution (GISR) related to the Weichselian ice sheet in Fennoscandia and the Barents Sea. The surface loading effect and its effect on the gravitational potential is modeled by including changes in sediment thickness in the sea level equation following the method of Dalca et al. (2013). Sediment displacement estimates are estimated in two different ways: (i) from a compilation of studies on local features (trough mouth fans, large-scale failures, and basin flux) and (ii) from output of a coupled ice-sediment model. To account for uncertainty in Earth's rheology, three viscosity profiles are used. It is found that sediment transport can lead to changes in relative sea level of up to 2 m in the last 6000 years and larger effects occurring earlier in the deglaciation. This magnitude is below the error level of most of the relative sea level data because those data are sparse and errors increase with length of time before present. The effect on present-day uplift rates reaches a few tenths of millimeters per year in large parts of Norway and Sweden, which is around the measurement error of long-term GNSS (global navigation satellite system) monitoring networks. The maximum effect on present-day gravity rates as measured by the GRACE (Gravity Recovery and Climate Experiment) satellite mission is up to tenths of microgal per year, which is larger than the measurement error but below other error sources. Since GISR causes systematic uplift in most of mainland Scandinavia, including GISR in GIA models would improve the interpretation of GNSS and GRACE observations there.

Influence of the number of elongated fiducial markers on the localization accuracy of the prostate

NASA Astrophysics Data System (ADS)

de Boer, Johan; de Bois, Josien; van Herk, Marcel; Sonke, Jan-Jakob

2012-10-01

Implanting fiducial markers for localization purposes has become an accepted practice in radiotherapy for prostate cancer. While many correction strategies correct for translations only, advanced correction protocols also require knowledge of the rotation of the prostate. For this purpose, typically, three or more markers are implanted. Elongated fiducial markers provide more information about their orientation than traditional round or cylindrical markers. Potentially, fewer markers are required. In this study, we evaluate the effect of the number of elongated markers on the localization accuracy of the prostate. To quantify the localization error, we developed a model that estimates, at arbitrary locations in the prostate, the registration error caused by translational and rotational uncertainties of the marker registration. Every combination of one, two and three markers was analysed for a group of 24 patients. The average registration errors at the prostate surface were 0.3-0.8 mm and 0.4-1 mm for registrations on, respectively, three markers and two markers located on different sides of the prostate. Substantial registration errors (2.0-2.2 mm) occurred at the prostate surface contralateral to the markers when two markers were implanted on the same side of the prostate or only one marker was used. In conclusion, there is no benefit in using three elongated markers: two markers accurately localize the prostate if they are implanted at some distance from each other.

Uncoupling nicotine mediated motoneuron axonal pathfinding errors and muscle degeneration in zebrafish

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

Welsh, Lillian; Tanguay, Robert L.; Svoboda, Kurt R.

Zebrafish embryos offer a unique opportunity to investigate the mechanisms by which nicotine exposure impacts early vertebrate development. Embryos exposed to nicotine become functionally paralyzed by 42 hpf suggesting that the neuromuscular system is compromised in exposed embryos. We previously demonstrated that secondary spinal motoneurons in nicotine-exposed embryos were delayed in development and that their axons made pathfinding errors (Svoboda, K.R., Vijayaraghaven, S., Tanguay, R.L., 2002. Nicotinic receptors mediate changes in spinal motoneuron development and axonal pathfinding in embryonic zebrafish exposed to nicotine. J. Neurosci. 22, 10731-10741). In that study, we did not consider the potential role that altered skeletalmore » muscle development caused by nicotine exposure could play in contributing to the errors in spinal motoneuron axon pathfinding. In this study, we show that an alteration in skeletal muscle development occurs in tandem with alterations in spinal motoneuron development upon exposure to nicotine. The alteration in the muscle involves the binding of nicotine to the muscle-specific AChRs. The nicotine-induced alteration in muscle development does not occur in the zebrafish mutant (sofa potato, [sop]), which lacks muscle-specific AChRs. Even though muscle development is unaffected by nicotine exposure in sop mutants, motoneuron axonal pathfinding errors still occur in these mutants, indicating a direct effect of nicotine exposure on nervous system development.« less

Effect of patient positions on measurement errors of the knee-joint space on radiographs

NASA Astrophysics Data System (ADS)

Gilewska, Grazyna

2001-08-01

Osteoarthritis (OA) is one of the most important health problems these days. It is one of the most frequent causes of pain and disability of middle-aged and old people. Nowadays the radiograph is the most economic and available tool to evaluate changes in OA. Error of performance of radiographs of knee joint is the basic problem of their evaluation for clinical research. The purpose of evaluation of such radiographs in my study was measuring the knee-joint space on several radiographs performed at defined intervals. Attempt at evaluating errors caused by a radiologist of a patient was presented in this study. These errors resulted mainly from either incorrect conditions of performance or from a patient's fault. Once we have information about size of the errors, we will be able to assess which of these elements have the greatest influence on accuracy and repeatability of measurements of knee-joint space. And consequently we will be able to minimize their sources.

Effect of phase errors in stepped-frequency radar systems

NASA Astrophysics Data System (ADS)

Vanbrundt, H. E.

1988-04-01

Stepped-frequency waveforms are being considered for inverse synthetic aperture radar (ISAR) imaging from ship and airborne platforms and for detailed radar cross section (RCS) measurements of ships and aircraft. These waveforms make it possible to achieve resolutions of 1.0 foot by using existing radar designs and processing technology. One problem not yet fully resolved in using stepped-frequency waveform for ISAR imaging is the deterioration in signal level caused by random frequency error. Random frequency error of the stepped-frequency source results in reduced peak responses and increased null responses. The resulting reduced signal-to-noise ratio is range dependent. Two of the major concerns addressed in this report are radar range limitations for ISAR and the error in calibration for RCS measurements caused by differences in range between a passive reflector used for an RCS reference and the target to be measured. In addressing these concerns, NOSC developed an analysis to assess the tolerable frequency error in terms of resulting power loss in signal power and signal-to-phase noise.

Effective Algorithm for Detection and Correction of the Wave Reconstruction Errors Caused by the Tilt of Reference Wave in Phase-shifting Interferometry

NASA Astrophysics Data System (ADS)

Xu, Xianfeng; Cai, Luzhong; Li, Dailin; Mao, Jieying

2010-04-01

In phase-shifting interferometry (PSI) the reference wave is usually supposed to be an on-axis plane wave. But in practice a slight tilt of reference wave often occurs, and this tilt will introduce unexpected errors of the reconstructed object wave-front. Usually the least-square method with iterations, which is time consuming, is employed to analyze the phase errors caused by the tilt of reference wave. Here a simple effective algorithm is suggested to detect and then correct this kind of errors. In this method, only some simple mathematic operation is used, avoiding using least-square equations as needed in most methods reported before. It can be used for generalized phase-shifting interferometry with two or more frames for both smooth and diffusing objects, and the excellent performance has been verified by computer simulations. The numerical simulations show that the wave reconstruction errors can be reduced by 2 orders of magnitude.

GPS Attitude Determination Using Deployable-Mounted Antennas

NASA Technical Reports Server (NTRS)

Osborne, Michael L.; Tolson, Robert H.

1996-01-01

The primary objective of this investigation is to develop a method to solve for spacecraft attitude in the presence of potential incomplete antenna deployment. Most research on the use of the Global Positioning System (GPS) in attitude determination has assumed that the antenna baselines are known to less than 5 centimeters, or one quarter of the GPS signal wavelength. However, if the GPS antennas are mounted on a deployable fixture such as a solar panel, the actual antenna positions will not necessarily be within 5 cm of nominal. Incomplete antenna deployment could cause the baselines to be grossly in error, perhaps by as much as a meter. Overcoming this large uncertainty in order to accurately determine attitude is the focus of this study. To this end, a two-step solution method is proposed. The first step uses a least-squares estimate of the baselines to geometrically calculate the deployment angle errors of the solar panels. For the spacecraft under investigation, the first step determines the baselines to 3-4 cm with 4-8 minutes of data. A Kalman filter is then used to complete the attitude determination process, resulting in typical attitude errors of 0.50.

Noncontact methods for measuring water-surface elevations and velocities in rivers: Implications for depth and discharge extraction

USGS Publications Warehouse

Nelson, Jonathan M.; Kinzel, Paul J.; McDonald, Richard R.; Schmeeckle, Mark

2016-01-01

Recently developed optical and videographic methods for measuring water-surface properties in a noninvasive manner hold great promise for extracting river hydraulic and bathymetric information. This paper describes such a technique, concentrating on the method of infrared videog- raphy for measuring surface velocities and both acoustic (laboratory-based) and laser-scanning (field-based) techniques for measuring water-surface elevations. In ideal laboratory situations with simple flows, appropriate spatial and temporal averaging results in accurate water-surface elevations and water-surface velocities. In test cases, this accuracy is sufficient to allow direct inversion of the governing equations of motion to produce estimates of depth and discharge. Unlike other optical techniques for determining local depth that rely on transmissivity of the water column (bathymetric lidar, multi/hyperspectral correlation), this method uses only water-surface information, so even deep and/or turbid flows can be investigated. However, significant errors arise in areas of nonhydrostatic spatial accelerations, such as those associated with flow over bedforms or other relatively steep obstacles. Using laboratory measurements for test cases, the cause of these errors is examined and both a simple semi-empirical method and computational results are presented that can potentially reduce bathymetric inversion errors.

Close-range radar rainfall estimation and error analysis

NASA Astrophysics Data System (ADS)

van de Beek, C. Z.; Leijnse, H.; Hazenberg, P.; Uijlenhoet, R.

2016-08-01

Quantitative precipitation estimation (QPE) using ground-based weather radar is affected by many sources of error. The most important of these are (1) radar calibration, (2) ground clutter, (3) wet-radome attenuation, (4) rain-induced attenuation, (5) vertical variability in rain drop size distribution (DSD), (6) non-uniform beam filling and (7) variations in DSD. This study presents an attempt to separate and quantify these sources of error in flat terrain very close to the radar (1-2 km), where (4), (5) and (6) only play a minor role. Other important errors exist, like beam blockage, WLAN interferences and hail contamination and are briefly mentioned, but not considered in the analysis. A 3-day rainfall event (25-27 August 2010) that produced more than 50 mm of precipitation in De Bilt, the Netherlands, is analyzed using radar, rain gauge and disdrometer data. Without any correction, it is found that the radar severely underestimates the total rain amount (by more than 50 %). The calibration of the radar receiver is operationally monitored by analyzing the received power from the sun. This turns out to cause a 1 dB underestimation. The operational clutter filter applied by KNMI is found to incorrectly identify precipitation as clutter, especially at near-zero Doppler velocities. An alternative simple clutter removal scheme using a clear sky clutter map improves the rainfall estimation slightly. To investigate the effect of wet-radome attenuation, stable returns from buildings close to the radar are analyzed. It is shown that this may have caused an underestimation of up to 4 dB. Finally, a disdrometer is used to derive event and intra-event specific Z-R relations due to variations in the observed DSDs. Such variations may result in errors when applying the operational Marshall-Palmer Z-R relation. Correcting for all of these effects has a large positive impact on the radar-derived precipitation estimates and yields a good match between radar QPE and gauge measurements, with a difference of 5-8 %. This shows the potential of radar as a tool for rainfall estimation, especially at close ranges, but also underlines the importance of applying radar correction methods as individual errors can have a large detrimental impact on the QPE performance of the radar.

Changes in mortality of Yellowstone's grizzly bears

USGS Publications Warehouse

Mattson, David J.

1998-01-01

Records of grizzly bear (Ursus arctos) deaths are currently used by managers to indicate trends in actual grizzly bear mortality and to judge the effectiveness of management. Two assumptions underlie these current uses: first, that recorded mortality is an unbiased indicator of actual mortality, and second, that changes in mortality after implementation of management strategies are sufficient grounds to infer the effects of management. I examined the defensibility of these 2 assumptions relative to alternate explanations, circumstantial evidence, and the potential costs of error. The potentially complex relation between actual and recorded mortality, as currently tallied and used, was reason to expect that the association between these 2 values would be weak. This expectation was supported by the prevalence (60-76%) of radio-marked bears among recorded deaths, the variation in apparent likelihood of documentation among causes of death, and variation in the prevalence of different causes over time. For these reasons, recorded mortality is likely to be an unreliable indicator of actual mortality. Use of whitebark pine (Pinus albicaulis) seeds by grizzly bears had a major effect on annual variation in recorded mortality. Low numbers of recorded deaths, 1984-92, were attributable to relatively frequent large whitebark pine seed crops. There was little or no residual trend potentially ascribed to management intervention during 1976-92. Management intervention was probably responsible for observed changes in recorded causes of death and stabilized recorded mortality over the period covered by this analysis.

Partial compensation interferometry measurement system for parameter errors of conicoid surface

NASA Astrophysics Data System (ADS)

Hao, Qun; Li, Tengfei; Hu, Yao; Wang, Shaopu; Ning, Yan; Chen, Zhuo

2018-06-01

Surface parameters, such as vertex radius of curvature and conic constant, are used to describe the shape of an aspheric surface. Surface parameter errors (SPEs) are deviations affecting the optical characteristics of an aspheric surface. Precise measurement of SPEs is critical in the evaluation of optical surfaces. In this paper, a partial compensation interferometry measurement system for SPE of a conicoid surface is proposed based on the theory of slope asphericity and the best compensation distance. The system is developed to measure the SPE-caused best compensation distance change and SPE-caused surface shape change and then calculate the SPEs with the iteration algorithm for accuracy improvement. Experimental results indicate that the average relative measurement accuracy of the proposed system could be better than 0.02% for the vertex radius of curvature error and 2% for the conic constant error.

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.

Error rates in forensic DNA analysis: definition, numbers, impact and communication.

PubMed

Kloosterman, Ate; Sjerps, Marjan; Quak, Astrid

2014-09-01

Forensic DNA casework is currently regarded as one of the most important types of forensic evidence, and important decisions in intelligence and justice are based on it. However, errors occasionally occur and may have very serious consequences. In other domains, error rates have been defined and published. The forensic domain is lagging behind concerning this transparency for various reasons. In this paper we provide definitions and observed frequencies for different types of errors at the Human Biological Traces Department of the Netherlands Forensic Institute (NFI) over the years 2008-2012. Furthermore, we assess their actual and potential impact and describe how the NFI deals with the communication of these numbers to the legal justice system. We conclude that the observed relative frequency of quality failures is comparable to studies from clinical laboratories and genetic testing centres. Furthermore, this frequency is constant over the five-year study period. The most common causes of failures related to the laboratory process were contamination and human error. Most human errors could be corrected, whereas gross contamination in crime samples often resulted in irreversible consequences. Hence this type of contamination is identified as the most significant source of error. Of the known contamination incidents, most were detected by the NFI quality control system before the report was issued to the authorities, and thus did not lead to flawed decisions like false convictions. However in a very limited number of cases crucial errors were detected after the report was issued, sometimes with severe consequences. Many of these errors were made in the post-analytical phase. The error rates reported in this paper are useful for quality improvement and benchmarking, and contribute to an open research culture that promotes public trust. However, they are irrelevant in the context of a particular case. Here case-specific probabilities of undetected errors are needed. These should be reported, separately from the match probability, when requested by the court or when there are internal or external indications for error. It should also be made clear that there are various other issues to consider, like DNA transfer. Forensic statistical models, in particular Bayesian networks, may be useful to take the various uncertainties into account and demonstrate their effects on the evidential value of the forensic DNA results. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

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 administration stages of the medication use process, with the majority of errors 82.0% (50/61) deemed to have originated in the community setting. The CARM pharmacovigilance database includes medication errors, many of which were found to originate in the community setting and reported as ADRs. Error-prone situations were able to be identified, providing greater opportunity to improve patient safety. However, to enhance detection of medication errors by pharmacovigilance centres, reports should be prospectively reviewed for preventability and the reporting form revised to facilitate capture of important information that will provide meaningful insight into the nature of the underlying systems defects that caused the error.

Purification of Logic-Qubit Entanglement.

PubMed

Zhou, Lan; Sheng, Yu-Bo

2016-07-05

Recently, the logic-qubit entanglement shows its potential application in future quantum communication and quantum network. However, the entanglement will suffer from the noise and decoherence. In this paper, we will investigate the first entanglement purification protocol for logic-qubit entanglement. We show that both the bit-flip error and phase-flip error in logic-qubit entanglement can be well purified. Moreover, the bit-flip error in physical-qubit entanglement can be completely corrected. The phase-flip in physical-qubit entanglement error equals to the bit-flip error in logic-qubit entanglement, which can also be purified. This entanglement purification protocol may provide some potential applications in future quantum communication and quantum network.

Error in telemetry studies: Effects of animal movement on triangulation

USGS Publications Warehouse

Schmutz, Joel A.; White, Gary C.

1990-01-01

We used Monte Carlo simulations to investigate the effects of animal movement on error of estimated animal locations derived from radio-telemetry triangulation of sequentially obtained bearings. Simulated movements of 0-534 m resulted in up to 10-fold increases in average location error but <10% decreases in location precision when observer-to-animal distances were <1,000 m. Location error and precision were minimally affected by censorship of poor locations with Chi-square goodness-of-fit tests. Location error caused by animal movement can only be eliminated by taking simultaneous bearings.

Implementation of Concept Mapping to Novices: Reasons for Errors, a Matter of Technique or Content?

ERIC Educational Resources Information Center

Conradty, Catherine; Bogner, Franz X.

2010-01-01

Concept mapping is discussed as a means to promote meaningful learning and in particular progress in reading comprehension skills. Its increasing implementation necessitates the acquisition of adequate knowledge about frequent errors in order to make available an effective introduction to the new learning method. To analyse causes of errors, 283…

How to Correct a Task Error: Task-Switch Effects Following Different Types of Error Correction

ERIC Educational Resources Information Center

Steinhauser, Marco

2010-01-01

It has been proposed that switch costs in task switching reflect the strengthening of task-related associations and that strengthening is triggered by response execution. The present study tested the hypothesis that only task-related responses are able to trigger strengthening. Effects of task strengthening caused by error corrections were…

Detecting genotyping errors and describing black bear movement in northern Idaho

Treesearch

Michael K. Schwartz; Samuel A. Cushman; Kevin S. McKelvey; Jim Hayden; Cory Engkjer

2006-01-01

Non-invasive genetic sampling has become a favored tool to enumerate wildlife. Genetic errors, caused by poor quality samples, can lead to substantial biases in numerical estimates of individuals. We demonstrate how the computer program DROPOUT can detect amplification errors (false alleles and allelic dropout) in a black bear (Ursus americanus) dataset collected in...

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.

Longitudinal Increase in Anisometropia in Older Adults

PubMed Central

Haegerstrom-Portnoy, Gunilla; Schneck, Marilyn E.; Lott, Lori A.; Hewlett, Susan E.; Brabyn, John A.

2014-01-01

Purpose Anisometropia shows an exponential increase in prevalence with increasing age based on cross-sectional studies. The purpose of this study was to evaluate longitudinal changes in anisometropia in all refractive components in older observers and to assess the influence of early cataract development. Methods Refractive error was assessed at two time points separated by ~12 years in 118 older observers (ages 67.1 and 79.3 years at the two test times). Anisometropia defined as ≥1.00 D was calculated for all refractive components. The subjects had intact ocular lenses in both eyes throughout the study. Lens evaluations were performed at the second test using LOCS III. Results All refractive components approximately doubled in prevalence of anisometropia. Spherical equivalent anisometropia changed from 16.1% to 32.2%. Similar changes were found for spherical error (17% to 38.1%), primary astigmatism (7.6% to 17.8%) and oblique astigmatism (14.4% to 29.7%). Many who did not have anisometropia at the first visit subsequently developed anisometropia (for ex. 26.3% for spherical error and 22.9% for oblique cylinder). The onset of anisometropia occurred at all ages within the studied age range with no particular preference for any one age. A small number lost anisometropia over time. Individual comparisons of refractive error changes in the two eyes in combination with nuclear lens changes showed that early changes in nuclear sclerosis in the two eyes could account for a large proportion of anisometropia (~40%) but unequal hyperopic shift in the spherical component in the two eyes was the primary cause of the anisometropia. Conclusions Anisometropia is at least 10 times more common in the elderly than in children and anisometropia develops in all refractive components in the oldest observers. Clinicians need to be aware of this common condition that could lead to binocular vision problems and potentially cause falls in the elderly. PMID:24276578

#2 - An Empirical Assessment of Exposure Measurement Error and Effect Attenuation in Bi-Pollutant Epidemiologic Models

EPA Science Inventory

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...

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.

SU-F-T-384: Step and Shoot IMRT, VMAT and Autoplan VMAT Nasopharnyx Plan Robustness to Linear Accelerator Delivery Errors

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

Pogson, EM; Liverpool and Macarthur Cancer Therapy Centres, Liverpool, NSW; Ingham Institute for Applied Medical Research, Sydney, NSW

Purpose: To identify the robustness of different treatment techniques in respect to simulated linac errors on the dose distribution to the target volume and organs at risk for step and shoot IMRT (ssIMRT), VMAT and Autoplan generated VMAT nasopharynx plans. Methods: A nasopharynx patient dataset was retrospectively replanned with three different techniques: 7 beam ssIMRT, one arc manual generated VMAT and one arc automatically generated VMAT. Treatment simulated uncertainties: gantry, collimator, MLC field size and MLC shifts, were introduced into these plans at increments of 5,2,1,−1,−2 and −5 (degrees or mm) and recalculated in Pinnacle. The mean and maximum dosesmore » were calculated for the high dose PTV, parotids, brainstem, and spinal cord and then compared to the original baseline plan. Results: Simulated gantry angle errors have <1% effect on the PTV, ssIMRT is most sensitive. The small collimator errors (±1 and ±2 degrees) impacted the mean PTV dose by <2% for all techniques, however for the ±5 degree errors mean target varied by up to 7% for the Autoplan VMAT and 10% for the max dose to the spinal cord and brain stem, seen in all techniques. The simulated MLC shifts introduced the largest errors for the Autoplan VMAT, with the larger MLC modulation presumably being the cause. The most critical error observed, was the MLC field size error, where even small errors of 1 mm, caused significant changes to both the PTV and the OAR. The ssIMRT is the least sensitive and the Autoplan the most sensitive, with target errors of up to 20% over and under dosages observed. Conclusion: For a nasopharynx patient the plan robustness observed is highest for the ssIMRT plan and lowest for the Autoplan generated VMAT plan. This could be caused by the more complex MLC modulation seen for the VMAT plans. This project is supported by a grant from NSW Cancer Council.« less

Variation of haemoglobin extinction coefficients can cause errors in the determination of haemoglobin concentration measured by near-infrared spectroscopy

NASA Astrophysics Data System (ADS)

Kim, J. G.; Liu, H.

2007-10-01

Near-infrared spectroscopy or imaging has been extensively applied to various biomedical applications since it can detect the concentrations of oxyhaemoglobin (HbO2), deoxyhaemoglobin (Hb) and total haemoglobin (Hbtotal) from deep tissues. To quantify concentrations of these haemoglobin derivatives, the extinction coefficient values of HbO2 and Hb have to be employed. However, it was not well recognized among researchers that small differences in extinction coefficients could cause significant errors in quantifying the concentrations of haemoglobin derivatives. In this study, we derived equations to estimate errors of haemoglobin derivatives caused by the variation of haemoglobin extinction coefficients. To prove our error analysis, we performed experiments using liquid-tissue phantoms containing 1% Intralipid in a phosphate-buffered saline solution. The gas intervention of pure oxygen was given in the solution to examine the oxygenation changes in the phantom, and 3 mL of human blood was added twice to show the changes in [Hbtotal]. The error calculation has shown that even a small variation (0.01 cm-1 mM-1) in extinction coefficients can produce appreciable relative errors in quantification of Δ[HbO2], Δ[Hb] and Δ[Hbtotal]. We have also observed that the error of Δ[Hbtotal] is not always larger than those of Δ[HbO2] and Δ[Hb]. This study concludes that we need to be aware of any variation in haemoglobin extinction coefficients, which could result from changes in temperature, and to utilize corresponding animal's haemoglobin extinction coefficients for the animal experiments, in order to obtain more accurate values of Δ[HbO2], Δ[Hb] and Δ[Hbtotal] from in vivo tissue measurements.

Reduction of Orifice-Induced Pressure Errors

NASA Technical Reports Server (NTRS)

Plentovich, Elizabeth B.; Gloss, Blair B.; Eves, John W.; Stack, John P.

1987-01-01

Use of porous-plug orifice reduces or eliminates errors, induced by orifice itself, in measuring static pressure on airfoil surface in wind-tunnel experiments. Piece of sintered metal press-fitted into static-pressure orifice so it matches surface contour of model. Porous material reduces orifice-induced pressure error associated with conventional orifice of same or smaller diameter. Also reduces or eliminates additional errors in pressure measurement caused by orifice imperfections. Provides more accurate measurements in regions with very thin boundary layers.

One wouldn't expect an expert bowler to hit only two pins: Hierarchical predictive processing of agent-caused events.

PubMed

Heil, Lieke; Kwisthout, Johan; van Pelt, Stan; van Rooij, Iris; Bekkering, Harold

2018-01-01

Evidence is accumulating that our brains process incoming information using top-down predictions. If lower level representations are correctly predicted by higher level representations, this enhances processing. However, if they are incorrectly predicted, additional processing is required at higher levels to "explain away" prediction errors. Here, we explored the potential nature of the models generating such predictions. More specifically, we investigated whether a predictive processing model with a hierarchical structure and causal relations between its levels is able to account for the processing of agent-caused events. In Experiment 1, participants watched animated movies of "experienced" and "novice" bowlers. The results are in line with the idea that prediction errors at a lower level of the hierarchy (i.e., the outcome of how many pins fell down) slow down reporting of information at a higher level (i.e., which agent was throwing the ball). Experiments 2 and 3 suggest that this effect is specific to situations in which the predictor is causally related to the outcome. Overall, the study supports the idea that a hierarchical predictive processing model can account for the processing of observed action outcomes and that the predictions involved are specific to cases where action outcomes can be predicted based on causal knowledge.

Cadence Tracking and Disturbance Rejection in Functional Electrical Stimulation Cycling for Paraplegic Subjects: A Case Study.

PubMed

Fonseca, Lucas O da; Bó, Antônio P L; Guimarães, Juliana A; Gutierrez, Miguel E; Fachin-Martins, Emerson

2017-11-01

Functional electrical stimulation cycling has been proposed as an assistive technology with numerous health and fitness benefits for people with spinal cord injury, such as improvement in cardiovascular function, increase in muscular mass, and reduction of bone mass loss. However, some limitations, for example, lack of optimal control strategies that would delay fatigue, may still prevent this technology from achieving its full potential. In this work, we performed experiments on a person with complete spinal cord injury using a stationary tadpole trike when both cadence tracking and disturbance rejection were evaluated. In addition, two sets of experiments were conducted 6 months apart and considering activation of different muscles. The results showed that reference tracking is achieved above the cadence of 25 rpm with mean absolute errors between 1.9 and 10% when only quadriceps are activated. The disturbance test revealed that interferences may drop the cadence but do not interrupt a continuous movement if the cadence does not drop below 25 rpm, again when only quadriceps are activated. When other muscle groups were added, strong spasticity caused larger errors on reference tracking, but not when a disturbance was applied. In addition, spasticity caused the last experiments to result in less smooth cycling. © 2017 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Pediatric vision screening using binocular retinal birefringencr scanning

NASA Astrophysics Data System (ADS)

Nassif, Deborah S.; Gramatikov, Boris; Guyton, David L.; Hunter, David G.

2003-07-01

Amblyopia, a leading cause of vision loss in childhood, is responsive to treatment if detected early in life. Risk factors for amblyopia, such as refractive error and strabismus, may be difficult to identify clinically in young children. Our laboratory has developed retinal birefringence scanning (RBS), in which a small spot of polarized light is scanned in a circle on the retina, and the returning light is measured for changes in polarization caused by the pattern of birefringent fibers that comprise the fovea. Binocular RBS (BRBS) detects the fixation of both eyes simultaneously and thus screens for strabismus, one of the risk factors of amblyopia. We have also developed a technique to automatically detect when the eye is in focus without measuring refractive error. This focus detection system utilizes a bull's eye photodetector optically conjugate to a point fixation source. Reflected light is focused back to the point source by the optical system of the eye, and if the subject focuses on the fixation source, the returning light will be focused on the detector. We have constructed a hand-held prototype combining BRBS and focus detection measurements in one quick (< 0.5 second) and accurate (theoretically detecting +/-1 of misalignment) measurement. This approach has the potential to reliably identify children at risk for amblyopia.

Evaluating Precipitation from Orbital Data Products of TRMM and GPM over the Indian Subcontinent

NASA Astrophysics Data System (ADS)

Jayaluxmi, I.; Kumar, D. N.

2015-12-01

The rapidly growing records of microwave based precipitation data made available from various earth observation satellites have instigated a pressing need towards evaluating the associated uncertainty which arise from different sources such as retrieval error, spatial/temporal sampling error and sensor dependent error. Pertaining to microwave remote sensing, most of the studies in literature focus on gridded data products, fewer studies exist on evaluating the uncertainty inherent in orbital data products. Evaluation of the latter are essential as they potentially cause large uncertainties during real time flood forecasting studies especially at the watershed scale. The present study evaluates the uncertainty of precipitation data derived from the orbital data products of the Tropical Rainfall Measuring Mission (TRMM) satellite namely the 2A12, 2A25 and 2B31 products. Case study results over the flood prone basin of Mahanadi, India, are analyzed for precipitation uncertainty through these three facets viz., a) Uncertainty quantification using the volumetric metrics from the contingency table [Aghakouchak and Mehran 2014] b) Error characterization using additive and multiplicative error models c) Error decomposition to identify systematic and random errors d) Comparative assessment with the orbital data from GPM mission. The homoscedastic random errors from multiplicative error models justify a better representation of precipitation estimates by the 2A12 algorithm. It can be concluded that although the radiometer derived 2A12 precipitation data is known to suffer from many sources of uncertainties, spatial analysis over the case study region of India testifies that they are in excellent agreement with the reference estimates for the data period considered [Indu and Kumar 2015]. References A. AghaKouchak and A. Mehran (2014), Extended contingency table: Performance metrics for satellite observations and climate model simulations, Water Resources Research, vol. 49, 7144-7149; J. Indu and D. Nagesh Kumar (2015), Evaluation of Precipitation Retrievals from Orbital Data Products of TRMM over a Subtropical basin in India, IEEE Transactions on Geoscience and Remote Sensing, in press, doi: 10.1109/TGRS.2015.2440338.

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

PubMed

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

2016-06-25

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

Health Equity and the Fallacy of Treating Causes of Population Health as if They Sum to 100.

PubMed

Krieger, Nancy

2017-04-01

Numerous examples exist in population health of work that erroneously forces the causes of health to sum to 100%. This is surprising. Clear refutations of this error extend back 80 years. Because public health analysis, action, and allocation of resources are ill served by faulty methods, I consider why this error persists. I first review several high-profile examples, including Doll and Peto's 1981 opus on the causes of cancer and its current interpretations; a 2015 high-publicity article in Science claiming that two thirds of cancer is attributable to chance; and the influential Web site "County Health Rankings & Roadmaps: Building a Culture of Health, County by County," whose model sums causes of health to equal 100%: physical environment (10%), social and economic factors (40%), clinical care (20%), and health behaviors (30%). Critical analysis of these works and earlier historical debates reveals that underlying the error of forcing causes of health to sum to 100% is the still dominant but deeply flawed view that causation can be parsed as nature versus nurture. Better approaches exist for tallying risk and monitoring efforts to reach health equity.

Health Equity and the Fallacy of Treating Causes of Population Health as if They Sum to 100%

PubMed Central

2017-01-01

Numerous examples exist in population health of work that erroneously forces the causes of health to sum to 100%. This is surprising. Clear refutations of this error extend back 80 years. Because public health analysis, action, and allocation of resources are ill served by faulty methods, I consider why this error persists. I first review several high-profile examples, including Doll and Peto’s 1981 opus on the causes of cancer and its current interpretations; a 2015 high-publicity article in Science claiming that two thirds of cancer is attributable to chance; and the influential Web site “County Health Rankings & Roadmaps: Building a Culture of Health, County by County,” whose model sums causes of health to equal 100%: physical environment (10%), social and economic factors (40%), clinical care (20%), and health behaviors (30%). Critical analysis of these works and earlier historical debates reveals that underlying the error of forcing causes of health to sum to 100% is the still dominant but deeply flawed view that causation can be parsed as nature versus nurture. Better approaches exist for tallying risk and monitoring efforts to reach health equity. PMID:28272952

Accuracy of measurement in electrically evoked compound action potentials.

PubMed

Hey, Matthias; Müller-Deile, Joachim

2015-01-15

Electrically evoked compound action potentials (ECAP) in cochlear implant (CI) patients are characterized by the amplitude of the N1P1 complex. The measurement of evoked potentials yields a combination of the measured signal with various noise components but for ECAP procedures performed in the clinical routine, only the averaged curve is accessible. To date no detailed analysis of error dimension has been published. The aim of this study was to determine the error of the N1P1 amplitude and to determine the factors that impact the outcome. Measurements were performed on 32 CI patients with either CI24RE (CA) or CI512 implants using the Software Custom Sound EP (Cochlear). N1P1 error approximation of non-averaged raw data consisting of recorded single-sweeps was compared to methods of error approximation based on mean curves. The error approximation of the N1P1 amplitude using averaged data showed comparable results to single-point error estimation. The error of the N1P1 amplitude depends on the number of averaging steps and amplification; in contrast, the error of the N1P1 amplitude is not dependent on the stimulus intensity. Single-point error showed smaller N1P1 error and better coincidence with 1/√(N) function (N is the number of measured sweeps) compared to the known maximum-minimum criterion. Evaluation of N1P1 amplitude should be accompanied by indication of its error. The retrospective approximation of this measurement error from the averaged data available in clinically used software is possible and best done utilizing the D-trace in forward masking artefact reduction mode (no stimulation applied and recording contains only the switch-on-artefact). Copyright © 2014 Elsevier B.V. All rights reserved.

Localized landslide risk assessment with multi pass L band DInSAR analysis

NASA Astrophysics Data System (ADS)

Yun, HyeWon; Rack Kim, Jung; Lin, Shih-Yuan; Choi, YunSoo

2014-05-01

In terms of data availability and error correction, landslide forecasting by Differential Interferometric SAR (DInSAR) analysis is not easy task. Especially, the landslides by the anthropogenic construction activities frequently occurred in the localized cutting side of mountainous area. In such circumstances, it is difficult to attain sufficient enough accuracy because of the external factors inducing the error component in electromagnetic wave propagation. For instance, the local climate characteristics such as orographic effect and the proximity to water source can produce the significant anomalies in the water vapor distribution and consequently result in the error components of InSAR phase angle measurements. Moreover the high altitude parts of target area cause the stratified tropospheric delay error in DInSAR measurement. The other obstacle in DInSAR observation over the potential landside site is the vegetation canopy which causes the decorrelation of InSAR phase. Thus rather than C band sensor such as ENVISAT, ERS and RADARSAT, DInSAR analysis with L band ALOS PLASAR is more recommendable. Together with the introduction of L band DInSAR analysis, the improved DInSAR technique to cope all above obstacles is necessary. Thus we employed two approaches i.e. StaMPS/MTI (Stanford Method for Persistent Scatterers/Multi-Temporal InSAR, Hopper et al., 2007) which was newly developed for extracting the reliable deformation values through time series analysis and two pass DInSAR with the error term compensation based on the external weather information in this study. Since the water vapor observation from spaceborne radiometer is not feasible by the temporal gap in this case, the quantities from weather Research Forecasting (WRF) with 1 km spatial resolution was used to address the atmospheric phase error in two pass DInSAR analysis. Also it was observed that base DEM offset with time dependent perpendicular baselines of InSAR time series produce a significant error even in the advanced time series techniques such as StaMPS/MTI. We tried to compensate with the algorithmic base together with the usage of high resolution LIDAR DEM. The target area of this study is the eastern part of Korean peninsula centered. In there, the landslide originated by the geomorphic factors such as high sloped topography and localized torrential down pour is critical issue. The surface deformations from error corrected two pass DInSAR and StaMPS/MTI are crossly compared and validated with the landslide triggering factors such as vegetation, slope and geological properties. The study will be further extended for the application of future SAR sensors by incorporating the dynamic analysis of topography to implement practical landslide forecasting scheme.

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

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.

Four dimensional observations of clouds from geosynchronous orbit using stereo display and measurement techniques on an interactive information processing system

NASA Technical Reports Server (NTRS)

Hasler, A. F.; Desjardins, M.; Shenk, W. E.

1979-01-01

Simultaneous Geosynchronous Operational Environmental Satellite (GOES) 1 km resolution visible image pairs can provide quantitative three dimensional measurements of clouds. These data have great potential for severe storms research and as a basic parameter measurement source for other areas of meteorology (e.g. climate). These stereo cloud height measurements are not subject to the errors and ambiguities caused by unknown cloud emissivity and temperature profiles that are associated with infrared techniques. This effort describes the display and measurement of stereo data using digital processing techniques.

Modeling And Detecting Anomalies In Scada Systems

NASA Astrophysics Data System (ADS)

Svendsen, Nils; Wolthusen, Stephen

The detection of attacks and intrusions based on anomalies is hampered by the limits of specificity underlying the detection techniques. However, in the case of many critical infrastructure systems, domain-specific knowledge and models can impose constraints that potentially reduce error rates. At the same time, attackers can use their knowledge of system behavior to mask their manipulations, causing adverse effects to observed only after a significant period of time. This paper describes elementary statistical techniques that can be applied to detect anomalies in critical infrastructure networks. A SCADA system employed in liquefied natural gas (LNG) production is used as a case study.

Predicted Deepwater Bathymetry from Satellite Altimetry: Non-Fourier Transform Alternatives

NASA Astrophysics Data System (ADS)

Salazar, M.; Elmore, P. A.

2017-12-01

Robert Parker (1972) demonstrated the effectiveness of Fourier Transforms (FT) to compute gravitational potential anomalies caused by uneven, non-uniform layers of material. This important calculation relates the gravitational potential anomaly to sea-floor topography. As outlined by Sandwell and Smith (1997), a six-step procedure, utilizing the FT, then demonstrated how satellite altimetry measurements of marine geoid height are inverted into seafloor topography. However, FTs are not local in space and produce Gibb's phenomenon around discontinuities. Seafloor features exhibit spatial locality and features such as seamounts and ridges often have sharp inclines. Initial tests compared the windowed-FT to wavelets in reconstruction of the step and saw-tooth functions and resulted in lower RMS error with fewer coefficients. This investigation, thus, examined the feasibility of utilizing sparser base functions such as the Mexican Hat Wavelet, which is local in space, to first calculate the gravitational potential, and then relate it to sea-floor topography.

Improving laboratory data entry quality using Six Sigma.

PubMed

Elbireer, Ali; Le Chasseur, Julie; Jackson, Brooks

2013-01-01

The Uganda Makerere University provides clinical laboratory support to over 70 clients in Uganda. With increased volume, manual data entry errors have steadily increased, prompting laboratory managers to employ the Six Sigma method to evaluate and reduce their problems. The purpose of this paper is to describe how laboratory data entry quality was improved by using Six Sigma. The Six Sigma Quality Improvement (QI) project team followed a sequence of steps, starting with defining project goals, measuring data entry errors to assess current performance, analyzing data and determining data-entry error root causes. Finally the team implemented changes and control measures to address the root causes and to maintain improvements. Establishing the Six Sigma project required considerable resources and maintaining the gains requires additional personnel time and dedicated resources. After initiating the Six Sigma project, there was a 60.5 percent reduction in data entry errors from 423 errors a month (i.e. 4.34 Six Sigma) in the first month, down to an average 166 errors/month (i.e. 4.65 Six Sigma) over 12 months. The team estimated the average cost of identifying and fixing a data entry error to be $16.25 per error. Thus, reducing errors by an average of 257 errors per month over one year has saved the laboratory an estimated $50,115 a year. The Six Sigma QI project provides a replicable framework for Ugandan laboratory staff and other resource-limited organizations to promote quality environment. Laboratory staff can deliver excellent care at a lower cost, by applying QI principles. This innovative QI method of reducing data entry errors in medical laboratories may improve the clinical workflow processes and make cost savings across the health care continuum.

SBL-Online: Implementing Studio-Based Learning Techniques in an Online Introductory Programming Course to Address Common Programming Errors and Misconceptions

ERIC Educational Resources Information Center

Polo, Blanca J.

2013-01-01

Much research has been done in regards to student programming errors, online education and studio-based learning (SBL) in computer science education. This study furthers this area by bringing together this knowledge and applying it to proactively help students overcome impasses caused by common student programming errors. This project proposes a…

Student Errors in Fractions and Possible Causes of These Errors

ERIC Educational Resources Information Center

Aksoy, Nuri Can; Yazlik, Derya Ozlem

2017-01-01

In this study, it was aimed to determine the errors and misunderstandings of 5th and 6th grade middle school students in fractions and operations with fractions. For this purpose, the case study model, which is a qualitative research design, was used in the research. In the study, maximum diversity sampling, which is a purposeful sampling method,…

Analysis and Compensation for Lateral Chromatic Aberration in a Color Coding Structured Light 3D Measurement System.

PubMed

Huang, Junhui; Xue, Qi; Wang, Zhao; Gao, Jianmin

2016-09-03

While color-coding methods have improved the measuring efficiency of a structured light three-dimensional (3D) measurement system, they decreased the measuring accuracy significantly due to lateral chromatic aberration (LCA). In this study, the LCA in a structured light measurement system is analyzed, and a method is proposed to compensate the error caused by the LCA. Firstly, based on the projective transformation, a 3D error map of LCA is constructed in the projector images by using a flat board and comparing the image coordinates of red, green and blue circles with the coordinates of white circles at preselected sample points within the measurement volume. The 3D map consists of the errors, which are the equivalent errors caused by LCA of the camera and projector. Then in measurements, error values of LCA are calculated and compensated to correct the projector image coordinates through the 3D error map and a tri-linear interpolation method. Eventually, 3D coordinates with higher accuracy are re-calculated according to the compensated image coordinates. The effectiveness of the proposed method is verified in the following experiments.

Analysis and Compensation for Lateral Chromatic Aberration in a Color Coding Structured Light 3D Measurement System

PubMed Central

Huang, Junhui; Xue, Qi; Wang, Zhao; Gao, Jianmin

2016-01-01

While color-coding methods have improved the measuring efficiency of a structured light three-dimensional (3D) measurement system, they decreased the measuring accuracy significantly due to lateral chromatic aberration (LCA). In this study, the LCA in a structured light measurement system is analyzed, and a method is proposed to compensate the error caused by the LCA. Firstly, based on the projective transformation, a 3D error map of LCA is constructed in the projector images by using a flat board and comparing the image coordinates of red, green and blue circles with the coordinates of white circles at preselected sample points within the measurement volume. The 3D map consists of the errors, which are the equivalent errors caused by LCA of the camera and projector. Then in measurements, error values of LCA are calculated and compensated to correct the projector image coordinates through the 3D error map and a tri-linear interpolation method. Eventually, 3D coordinates with higher accuracy are re-calculated according to the compensated image coordinates. The effectiveness of the proposed method is verified in the following experiments. PMID:27598174

Drug error in paediatric anaesthesia: current status and where to go now.

PubMed

Anderson, Brian J

2018-06-01

Medication errors in paediatric anaesthesia and the perioperative setting continue to occur despite widespread recognition of the problem and published advice for reduction of this predicament at international, national, local and individual levels. Current literature was reviewed to ascertain drug error rates and to appraise causes and proposed solutions to reduce these errors. The medication error incidence remains high. There is documentation of reduction through identification of causes with consequent education and application of safety analytics and quality improvement programs in anaesthesia departments. Children remain at higher risk than adults because of additional complexities such as drug dose calculations, increased susceptibility to some adverse effects and changes associated with growth and maturation. Major improvements are best made through institutional system changes rather than a commitment to do better on the part of each practitioner. Medication errors in paediatric anaesthesia represent an important risk to children and most are avoidable. There is now an understanding of the genesis of adverse drug events and this understanding should facilitate the implementation of known effective countermeasures. An institution-wide commitment and strategy are the basis for a worthwhile and sustained improvement in medication safety.

Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error.

PubMed

Treleaven, Julia; Jull, Gwendolen; Sterling, Michele

2003-01-01

Dizziness and/or unsteadiness are common symptoms of chronic whiplash-associated disorders. This study aimed to report the characteristics of these symptoms and determine whether there was any relationship to cervical joint position error. Joint position error, the accuracy to return to the natural head posture following extension and rotation, was measured in 102 subjects with persistent whiplash-associated disorder and 44 control subjects. Whiplash subjects completed a neck pain index and answered questions about the characteristics of dizziness. The results indicated that subjects with whiplash-associated disorders had significantly greater joint position errors than control subjects. Within the whiplash group, those with dizziness had greater joint position errors than those without dizziness following rotation (rotation (R) 4.5 degrees (0.3) vs 2.9 degrees (0.4); rotation (L) 3.9 degrees (0.3) vs 2.8 degrees (0.4) respectively) and a higher neck pain index (55.3% (1.4) vs 43.1% (1.8)). Characteristics of the dizziness were consistent for those reported for a cervical cause but no characteristics could predict the magnitude of joint position error. Cervical mechanoreceptor dysfunction is a likely cause of dizziness in whiplash-associated disorder.

37 CFR 2.125 - Filing and service of testimony.

Code of Federal Regulations, 2012 CFR

2012-07-01

... having all typographical errors in the transcript and all errors of arrangement, indexing and form of the...(g) with respect to arrangement, indexing and form. (e) Upon motion by any party, for good cause, the...

37 CFR 2.125 - Filing and service of testimony.

Code of Federal Regulations, 2013 CFR

2013-07-01

... having all typographical errors in the transcript and all errors of arrangement, indexing and form of the...(g) with respect to arrangement, indexing and form. (e) Upon motion by any party, for good cause, the...

37 CFR 2.125 - Filing and service of testimony.

Code of Federal Regulations, 2010 CFR

2010-07-01

... having all typographical errors in the transcript and all errors of arrangement, indexing and form of the...(g) with respect to arrangement, indexing and form. (e) Upon motion by any party, for good cause, the...

37 CFR 2.125 - Filing and service of testimony.

Code of Federal Regulations, 2011 CFR

2011-07-01

... having all typographical errors in the transcript and all errors of arrangement, indexing and form of the...(g) with respect to arrangement, indexing and form. (e) Upon motion by any party, for good cause, the...

37 CFR 2.125 - Filing and service of testimony.

Code of Federal Regulations, 2014 CFR

2014-07-01

... having all typographical errors in the transcript and all errors of arrangement, indexing and form of the...(g) with respect to arrangement, indexing and form. (e) Upon motion by any party, for good cause, the...

Purification of Logic-Qubit Entanglement

PubMed Central

Zhou, Lan; Sheng, Yu-Bo

2016-01-01

Recently, the logic-qubit entanglement shows its potential application in future quantum communication and quantum network. However, the entanglement will suffer from the noise and decoherence. In this paper, we will investigate the first entanglement purification protocol for logic-qubit entanglement. We show that both the bit-flip error and phase-flip error in logic-qubit entanglement can be well purified. Moreover, the bit-flip error in physical-qubit entanglement can be completely corrected. The phase-flip in physical-qubit entanglement error equals to the bit-flip error in logic-qubit entanglement, which can also be purified. This entanglement purification protocol may provide some potential applications in future quantum communication and quantum network. PMID:27377165

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

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

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

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

Quasi-eccentricity error modeling and compensation in vision metrology

NASA Astrophysics Data System (ADS)

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

2018-04-01

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

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…

Analysis of the impact of error detection on computer performance

NASA Technical Reports Server (NTRS)

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

1983-01-01

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

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.

Corrigendum to “Thermophysical properties of U 3Si 2 to 1773 K”

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

White, Joshua Taylor; Nelson, Andrew Thomas; Dunwoody, John Tyler

2016-12-01

An error was discovered by the authors in the calculation of thermal diffusivity in “Thermophysical properties of U 3Si 2 to 1773 K”. The error was caused by operator error in entry of parameters used to fit the temperature rise versus time model necessary to calculate the thermal diffusivity. Lastly, this error propagated to the calculation of thermal conductivity, leading to values that were 18%–28% larger along with the corresponding calculated Lorenz values.

Experimental Verification of Sparse Aperture Mask for Low Order Wavefront Sensing

NASA Astrophysics Data System (ADS)

Subedi, Hari; Kasdin, N. Jeremy

2017-01-01

To directly image exoplanets, future space-based missions are equipped with coronagraphs which manipulate the diffraction of starlight and create regions of high contrast called dark holes. Theoretically, coronagraphs can be designed to achieve the high level of contrast required to image exoplanets, which are billions of times dimmer than their host stars, however the aberrations caused by optical imperfections and thermal fluctuations cause the degradation of contrast in the dark holes. Focal plane wavefront control (FPWC) algorithms using deformable mirrors (DMs) are used to mitigate the quasi-static aberrations caused by optical imperfections. Although the FPWC methods correct the quasi-static aberrations, they are blind to dynamic errors caused by telescope jitter and thermal fluctuations. At Princeton's High Contrast Imaging Lab we have developed a new technique that integrates a sparse aperture mask with the coronagraph to estimate these low-order dynamic wavefront errors. This poster shows the effectiveness of a SAM Low-Order Wavefront Sensor in estimating and correcting these errors via simulation and experiment and compares the results to other methods, such as the Zernike Wavefront Sensor planned for WFIRST.

Automatic-Control System for Safer Brazing

NASA Technical Reports Server (NTRS)

Stein, J. A.; Vanasse, M. A.

1986-01-01

Automatic-control system for radio-frequency (RF) induction brazing of metal tubing reduces probability of operator errors, increases safety, and ensures high-quality brazed joints. Unit combines functions of gas control and electric-power control. Minimizes unnecessary flow of argon gas into work area and prevents electrical shocks from RF terminals. Controller will not allow power to flow from RF generator to brazing head unless work has been firmly attached to head and has actuated micro-switch. Potential shock hazard eliminated. Flow of argon for purging and cooling must be turned on and adjusted before brazing power applied. Provision ensures power not applied prematurely, causing damaged work or poor-quality joints. Controller automatically turns off argon flow at conclusion of brazing so potentially suffocating gas does not accumulate in confined areas.

Brain-based individual difference measures of reading skill in deaf and hearing adults.

PubMed

Mehravari, Alison S; Emmorey, Karen; Prat, Chantel S; Klarman, Lindsay; Osterhout, Lee

2017-07-01

Most deaf children and adults struggle to read, but some deaf individuals do become highly proficient readers. There is disagreement about the specific causes of reading difficulty in the deaf population, and consequently, disagreement about the effectiveness of different strategies for teaching reading to deaf children. Much of the disagreement surrounds the question of whether deaf children read in similar or different ways as hearing children. In this study, we begin to answer this question by using real-time measures of neural language processing to assess if deaf and hearing adults read proficiently in similar or different ways. Hearing and deaf adults read English sentences with semantic, grammatical, and simultaneous semantic/grammatical errors while event-related potentials (ERPs) were recorded. The magnitude of individuals' ERP responses was compared to their standardized reading comprehension test scores, and potentially confounding variables like years of education, speechreading skill, and language background of deaf participants were controlled for. The best deaf readers had the largest N400 responses to semantic errors in sentences, while the best hearing readers had the largest P600 responses to grammatical errors in sentences. These results indicate that equally proficient hearing and deaf adults process written language in different ways, suggesting there is little reason to assume that literacy education should necessarily be the same for hearing and deaf children. The results also show that the most successful deaf readers focus on semantic information while reading, which suggests aspects of education that may promote improved literacy in the deaf population. Copyright © 2017 Elsevier Ltd. All rights reserved.

Abnormal Error Monitoring in Math-Anxious Individuals: Evidence from Error-Related Brain Potentials

PubMed Central

Suárez-Pellicioni, Macarena; Núñez-Peña, María Isabel; Colomé, Àngels

2013-01-01

This study used event-related brain potentials to investigate whether math anxiety is related to abnormal error monitoring processing. Seventeen high math-anxious (HMA) and seventeen low math-anxious (LMA) individuals were presented with a numerical and a classical Stroop task. Groups did not differ in terms of trait or state anxiety. We found enhanced error-related negativity (ERN) in the HMA group when subjects committed an error on the numerical Stroop task, but not on the classical Stroop task. Groups did not differ in terms of the correct-related negativity component (CRN), the error positivity component (Pe), classical behavioral measures or post-error measures. The amplitude of the ERN was negatively related to participants’ math anxiety scores, showing a more negative amplitude as the score increased. Moreover, using standardized low resolution electromagnetic tomography (sLORETA) we found greater activation of the insula in errors on a numerical task as compared to errors in a non-numerical task only for the HMA group. The results were interpreted according to the motivational significance theory of the ERN. PMID:24236212

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.

XCO2 retrieval error over deserts near critical surface albedo

NASA Astrophysics Data System (ADS)

Zhang, Qiong; Shia, Run-Lie; Sander, Stanley P.; Yung, Yuk L.

2016-02-01

Large retrieval errors in column-weighted CO2 mixing ratio (XCO2) over deserts are evident in the Orbiting Carbon Observatory 2 version 7 L2 products. We argue that these errors are caused by the surface albedo being close to a critical surface albedo (αc). Over a surface with albedo close to αc, increasing the aerosol optical depth (AOD) does not change the continuum radiance. The spectral signature caused by changing the AOD is identical to that caused by changing the absorbing gas column. The degeneracy in the retrievals of AOD and XCO2 results in a loss of degrees of freedom and information content. We employ a two-stream-exact single scattering radiative transfer model to study the physical mechanism of XCO2 retrieval error over a surface with albedo close to αc. Based on retrieval tests over surfaces with different albedos, we conclude that over a surface with albedo close to αc, the XCO2 retrieval suffers from a significant loss of accuracy. We recommend a bias correction approach that has significantly improved the XCO2 retrieval from the California Laboratory for Atmospheric Remote Sensing data in the presence of aerosol loading.

Eye of the Beholder: Stage Entrance Behavior and Facial Expression Affect Continuous Quality Ratings in Music Performance

PubMed Central

Waddell, George; Williamon, Aaron

2017-01-01

Judgments of music performance quality are commonly employed in music practice, education, and research. However, previous studies have demonstrated the limited reliability of such judgments, and there is now evidence that extraneous visual, social, and other “non-musical” features can unduly influence them. The present study employed continuous measurement techniques to examine how the process of forming a music quality judgment is affected by the manipulation of temporally specific visual cues. Video footage comprising an appropriate stage entrance and error-free performance served as the standard condition (Video 1). This footage was manipulated to provide four additional conditions, each identical save for a single variation: an inappropriate stage entrance (Video 2); the presence of an aural performance error midway through the piece (Video 3); the same error accompanied by a negative facial reaction by the performer (Video 4); the facial reaction with no corresponding aural error (Video 5). The participants were 53 musicians and 52 non-musicians (N = 105) who individually assessed the performance quality of one of the five randomly assigned videos via a digital continuous measurement interface and headphones. The results showed that participants viewing the “inappropriate” stage entrance made judgments significantly more quickly than those viewing the “appropriate” entrance, and while the poor entrance caused significantly lower initial scores among those with musical training, the effect did not persist long into the performance. The aural error caused an immediate drop in quality judgments that persisted to a lower final score only when accompanied by the frustrated facial expression from the pianist; the performance error alone caused a temporary drop only in the musicians' ratings, and the negative facial reaction alone caused no reaction regardless of participants' musical experience. These findings demonstrate the importance of visual information in forming evaluative and aesthetic judgments in musical contexts and highlight how visual cues dynamically influence those judgments over time. PMID:28487662

Aircraft measurements of the atmospheric electrical global circuit during the period 1971-1984

NASA Technical Reports Server (NTRS)

Markson, R.

1985-01-01

This report will update an investigation of the global circuit conducted over the last 14 years through aircraft measurements of the variation of ionospheric potential and associated parameters. The data base included electric field, conductivity, and air-earth current density profiles from the tropics (25 deg N) to the Arctic (79 deg N). Almost all of the data have been obtained over the ocean to reduce noise associated with local generators, aerosols, and convection. Recently, two aircraft have been utilized to obtain, for the first time, quasi-periodic sets of simultaneous ionospheric potential (VI) soundings at remote locations and extending over time spans sufficiently long so that the universal time diurnal variation (Carnegie curve) could be observed. In additon, these measurements provided the first detection of the modulation of electric fields in the troposphere caused by the double vortex ionospheric convection pattern. Besides summarizing these measurements and comparing them to similar data obtained by other groups, this report discusses meteorological sources of error and criteria for determining if the global circuit is being measured rather than variations caused by local meteorological processes.