STAMP-Based HRA Considering Causality Within a Sociotechnical System: A Case of Minuteman III Missile Accident.

PubMed

Rong, Hao; Tian, Jin

2015-05-01

The study contributes to human reliability analysis (HRA) by proposing a method that focuses more on human error causality within a sociotechnical system, illustrating its rationality and feasibility by using a case of the Minuteman (MM) III missile accident. Due to the complexity and dynamics within a sociotechnical system, previous analyses of accidents involving human and organizational factors clearly demonstrated that the methods using a sequential accident model are inadequate to analyze human error within a sociotechnical system. System-theoretic accident model and processes (STAMP) was used to develop a universal framework of human error causal analysis. To elaborate the causal relationships and demonstrate the dynamics of human error, system dynamics (SD) modeling was conducted based on the framework. A total of 41 contributing factors, categorized into four types of human error, were identified through the STAMP-based analysis. All factors are related to a broad view of sociotechnical systems, and more comprehensive than the causation presented in the accident investigation report issued officially. Recommendations regarding both technical and managerial improvement for a lower risk of the accident are proposed. The interests of an interdisciplinary approach provide complementary support between system safety and human factors. The integrated method based on STAMP and SD model contributes to HRA effectively. The proposed method will be beneficial to HRA, risk assessment, and control of the MM III operating process, as well as other sociotechnical systems. © 2014, Human Factors and Ergonomics Society.

Are "Human Factors" the Primary Cause of Complications in the Field of Implant Dentistry?

PubMed

Renouard, Franck; Amalberti, René; Renouard, Erell

Complications in medicine and dentistry are usually analyzed from a purely technical point of view. Rarely is the role of human behavior or judgment considered as a reason for adverse outcomes. When the role of human factors is considered, these are usually described in general terms rather than specifically identifying the factors responsible for an adverse event. The impact of cognitive and behavioral factors in the explanation of adverse events has been studied in other high-stakes areas such as aviation and nuclear power. Specific protocols have been developed to reduce rates of human error, and, where human error is unavoidable, to lessen its impact. This approach has dramatically reduced the incidence of accidents in these fields. This article aims to review how a similar approach may prove valuable in the reduction of complications in implant dentistry.

48 CFR 342.7101-2 - Procedures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Section 342.7101-2 Federal Acquisition Regulations System HEALTH AND HUMAN SERVICES CONTRACT MANAGEMENT... for the increase (e.g., error in estimate, changed conditions). (6) The latest date by which funds... data received; (2) Request audit or cost advisory services, and technical support, as necessary, for...

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2015-01-01

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

Accounting for measurement error: a critical but often overlooked process.

PubMed

Harris, Edward F; Smith, Richard N

2009-12-01

Due to instrument imprecision and human inconsistencies, measurements are not free of error. Technical error of measurement (TEM) is the variability encountered between dimensions when the same specimens are measured at multiple sessions. A goal of a data collection regimen is to minimise TEM. The few studies that actually quantify TEM, regardless of discipline, report that it is substantial and can affect results and inferences. This paper reviews some statistical approaches for identifying and controlling TEM. Statistically, TEM is part of the residual ('unexplained') variance in a statistical test, so accounting for TEM, which requires repeated measurements, enhances the chances of finding a statistically significant difference if one exists. The aim of this paper was to review and discuss common statistical designs relating to types of error and statistical approaches to error accountability. This paper addresses issues of landmark location, validity, technical and systematic error, analysis of variance, scaled measures and correlation coefficients in order to guide the reader towards correct identification of true experimental differences. Researchers commonly infer characteristics about populations from comparatively restricted study samples. Most inferences are statistical and, aside from concerns about adequate accounting for known sources of variation with the research design, an important source of variability is measurement error. Variability in locating landmarks that define variables is obvious in odontometrics, cephalometrics and anthropometry, but the same concerns about measurement accuracy and precision extend to all disciplines. With increasing accessibility to computer-assisted methods of data collection, the ease of incorporating repeated measures into statistical designs has improved. Accounting for this technical source of variation increases the chance of finding biologically true differences when they exist.

Prevalence of technical errors and periapical lesions in a sample of endodontically treated teeth: a CBCT analysis.

PubMed

Nascimento, Eduarda Helena Leandro; Gaêta-Araujo, Hugo; Andrade, Maria Fernanda Silva; Freitas, Deborah Queiroz

2018-01-21

The aims of this study are to identify the most frequent technical errors in endodontically treated teeth and to determine which root canals were most often associated with those errors, as well as to relate endodontic technical errors and the presence of coronal restorations with periapical status by means of cone-beam computed tomography images. Six hundred eighteen endodontically treated teeth (1146 root canals) were evaluated for the quality of their endodontic treatment and for the presence of coronal restorations and periapical lesions. Each root canal was classified according to dental groups, and the endodontic technical errors were recorded. Chi-square's test and descriptive analyses were performed. Six hundred eighty root canals (59.3%) had periapical lesions. Maxillary molars and anterior teeth showed higher prevalence of periapical lesions (p < 0.05). Endodontic treatment quality and coronal restoration were associated with periapical status (p < 0.05). Underfilling was the most frequent technical error in all root canals, except for the second mesiobuccal root canal of maxillary molars and the distobuccal root canal of mandibular molars, which were non-filled in 78.4 and 30% of the cases, respectively. There is a high prevalence of apical radiolucencies, which increased in the presence of poor coronal restorations, endodontic technical errors, and when both conditions were concomitant. Underfilling was the most frequent technical error, followed by non-homogeneous and non-filled canals. Evaluation of endodontic treatment quality that considers every single root canal aims on warning dental practitioners of the prevalence of technical errors that could be avoided with careful treatment planning and execution.

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.

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

PubMed

Qi, Yulin; Geib, Timon; Schorr, Pascal; Meier, Florian; Volmer, Dietrich A

2015-01-15

Isobaric interferences in human serum can potentially influence the measured concentration levels of 25-hydroxyvitamin D [25(OH)D], when low resolving power liquid chromatography/tandem mass spectrometry (LC/MS/MS) instruments and non-specific MS/MS product ions are employed for analysis. In this study, we provide a detailed characterization of these interferences and a technical solution to reduce the associated systematic errors. Detailed electrospray ionization Fourier transform ion cyclotron resonance (FTICR) high-resolution mass spectrometry (HRMS) experiments were used to characterize co-extracted isobaric components of 25(OH)D from human serum. Differential ion mobility spectrometry (DMS), as a gas-phase ion filter, was implemented on a triple quadrupole mass spectrometer for separation of the isobars. HRMS revealed the presence of multiple isobaric compounds in extracts of human serum for different sample preparation methods. Several of these isobars had the potential to increase the peak areas measured for 25(OH)D on low-resolution MS instruments. A major isobaric component was identified as pentaerythritol oleate, a technical lubricant, which was probably an artifact from the analytical instrumentation. DMS was able to remove several of these isobars prior to MS/MS, when implemented on the low-resolution triple quadrupole mass spectrometer. It was shown in this proof-of-concept study that DMS-MS has the potential to significantly decrease systematic errors, and thus improve accuracy of vitamin D measurements using LC/MS/MS. Copyright © 2014 John Wiley & Sons, Ltd.

Accuracy of Noninvasive Estimation Techniques for the State of the Cochlear Amplifier

NASA Astrophysics Data System (ADS)

Dalhoff, Ernst; Gummer, Anthony W.

2011-11-01

Estimation of the function of the cochlea in human is possible only by deduction from indirect measurements, which may be subjective or objective. Therefore, for basic research as well as diagnostic purposes, it is important to develop methods to deduce and analyse error sources of cochlear-state estimation techniques. Here, we present a model of technical and physiologic error sources contributing to the estimation accuracy of hearing threshold and the state of the cochlear amplifier and deduce from measurements of human that the estimated standard deviation can be considerably below 6 dB. Experimental evidence is drawn from two partly independent objective estimation techniques for the auditory signal chain based on measurements of otoacoustic emissions.

Study on Classification Accuracy Inspection of Land Cover Data Aided by Automatic Image Change Detection Technology

NASA Astrophysics Data System (ADS)

Xie, W.-J.; Zhang, L.; Chen, H.-P.; Zhou, J.; Mao, W.-J.

2018-04-01

The purpose of carrying out national geographic conditions monitoring is to obtain information of surface changes caused by human social and economic activities, so that the geographic information can be used to offer better services for the government, enterprise and public. Land cover data contains detailed geographic conditions information, thus has been listed as one of the important achievements in the national geographic conditions monitoring project. At present, the main issue of the production of the land cover data is about how to improve the classification accuracy. For the land cover data quality inspection and acceptance, classification accuracy is also an important check point. So far, the classification accuracy inspection is mainly based on human-computer interaction or manual inspection in the project, which are time consuming and laborious. By harnessing the automatic high-resolution remote sensing image change detection technology based on the ERDAS IMAGINE platform, this paper carried out the classification accuracy inspection test of land cover data in the project, and presented a corresponding technical route, which includes data pre-processing, change detection, result output and information extraction. The result of the quality inspection test shows the effectiveness of the technical route, which can meet the inspection needs for the two typical errors, that is, missing and incorrect update error, and effectively reduces the work intensity of human-computer interaction inspection for quality inspectors, and also provides a technical reference for the data production and quality control of the land cover data.

The Relationship Between Technical Errors and Decision Making Skills in the Junior Resident

PubMed Central

Nathwani, J. N.; Fiers, R.M.; Ray, R.D.; Witt, A.K.; Law, K. E.; DiMarco, S.M.; Pugh, C.M.

2017-01-01

Objective The purpose of this study is to co-evaluate resident technical errors and decision-making capabilities during placement of a subclavian central venous catheter (CVC). We hypothesize that there will be significant correlations between scenario based decision making skills, and technical proficiency in central line insertion. We also predict residents will have problems in anticipating common difficulties and generating solutions associated with line placement. Design Participants were asked to insert a subclavian central line on a simulator. After completion, residents were presented with a real life patient photograph depicting CVC placement and asked to anticipate difficulties and generate solutions. Error rates were analyzed using chi-square tests and a 5% expected error rate. Correlations were sought by comparing technical errors and scenario based decision making. Setting This study was carried out at seven tertiary care centers. Participants Study participants (N=46) consisted of largely first year research residents that could be followed longitudinally. Second year research and clinical residents were not excluded. Results Six checklist errors were committed more often than anticipated. Residents performed an average of 1.9 errors, significantly more than the 1 error, at most, per person expected (t(44)=3.82, p<.001). The most common error was performance of the procedure steps in the wrong order (28.5%, P<.001). Some of the residents (24%) had no errors, 30% committed one error, and 46 % committed more than one error. The number of technical errors committed negatively correlated with the total number of commonly identified difficulties and generated solutions (r(33)= −.429, p=.021, r(33)= −.383, p=.044 respectively). Conclusions Almost half of the surgical residents committed multiple errors while performing subclavian CVC placement. The correlation between technical errors and decision making skills suggests a critical need to train residents in both technique and error management. ACGME Competencies Medical Knowledge, Practice Based Learning and Improvement, Systems Based Practice PMID:27671618

Utilization of robotic-arm assisted total knee arthroplasty for soft tissue protection.

PubMed

Sultan, Assem A; Piuzzi, Nicolas; Khlopas, Anton; Chughtai, Morad; Sodhi, Nipun; Mont, Michael A

2017-12-01

Despite the well-established success of total knee arthroplasty (TKA), iatrogenic ligamentous and soft tissue injuries are infrequent, but potential complications that can have devastating impact on clinical outcomes. These injuries are often related to technical errors and excessive soft tissue manipulation, particularly during bony resections. Recently, robotic-arm assisted TKA was introduced and demonstrated promising results with potential technical advantages over manual surgery in implant positioning and mechanical accuracy. Furthermore, soft tissue protection is an additional potential advantage offered by these systems that can reduce inadvertent human technical errors encountered during standard manual resections. Therefore, due to the relative paucity of literature, we attempted to answer the following questions: 1) does robotic-arm assisted TKA offer a technical advantage that allows enhanced soft tissue protection? 2) What is the available evidence about soft tissue protection? Recently introduced models of robotic-arm assisted TKA systems with advanced technology showed promising clinical outcomes and soft tissue protection in the short- and mid-term follow-up with results comparable or superior to manual TKA. In this review, we attempted to explore this dimension of robotics in TKA and investigate the soft tissue related complications currently reported in the literature.

Human dignity and the future of the voluntary active euthanasia debate in South Africa.

PubMed

Jordaan, Donrich W

2017-04-25

The issue of voluntary active euthanasia was thrust into the public policy arena by the Stransham-Ford lawsuit. The High Court legalised voluntary active euthanasia - however, ostensibly only in the specific case of Mr Stransham-Ford. The Supreme Court of Appeal overturned the High Court judgment on technical grounds, not on the merits. This means that in future the courts can be approached again to consider the legalisation of voluntary active euthanasia. As such, Stransham-Ford presents a learning opportunity for both sides of the legalisation divide. In particular, conceptual errors pertaining to human dignity were made in Stransham-Ford, and can be avoided in future. In this article, I identify these errors and propose the following three corrective principles to inform future debate on the subject: (i) human dignity is violable; (ii) human suffering violates human dignity; and (iii) the 'natural' causes of suffering due to terminal illness do not exclude the application of human dignity.

75 FR 8374 - Medicare Program; Meeting of the Practicing Physicians Advisory Council, March 8, 2010; Correction

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-24

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1566-CN... 22, 2010 (75 FR 3743), there were a number of technical errors that are identified and corrected in... telephone at the number listed in the FOR FURTHER INFORMATION CONTACT section of this notice by the date...

Non-technical skills training to enhance patient safety.

PubMed

Gordon, Morris

2013-06-01

  Patient safety is an increasingly recognised issue in health care. Systems-based and organisational methods of quality improvement, as well as education focusing on key clinical areas, are common, but there are few reports of educational interventions that focus on non-technical skills to address human factor sources of error. A flexible model for non-technical skills training for health care professionals has been designed based on the best available evidence, and with sound theoretical foundations.   Educational sessions to improve non-technical skills in health care have been described before. The descriptions lack the details to allow educators to replicate and innovate further.   A non-technical skills training course that can be delivered as either a half- or full-day intervention has been designed and delivered to a number of mixed groups of undergraduate medical students and doctors in postgraduate training. Participant satisfaction has been high and patient safety attitudes have improved post-intervention.   This non-technical skills educational intervention has been built on a sound evidence base, and is described so as to facilitate replication and dissemination. With the key themes laid out, clinical educators will be able to build interventions focused on numerous clinical issues that pay attention to human factor contributors to safety. © 2013 John Wiley & Sons Ltd.

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

PubMed

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

2015-12-01

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

On operator strategic behavior

NASA Technical Reports Server (NTRS)

Hancock, P. A.

1991-01-01

Deeper and more detailed knowledge as to how human operators such as pilots respond, singly and in groups, to demands on their performance which arise from technical systems will support the manipulation of such systems' design in order to accommodate the foibles of human behavior. Efforts to understand how self-autonomy impacts strategic behavior and such related issues as error generation/recognition/correction are still in their infancy. The present treatment offers both general and aviation-specific definitions of strategic behavior as precursors of prospective investigations.

Towards an evaluation framework for Laboratory Information Systems.

PubMed

Yusof, Maryati M; Arifin, Azila

Laboratory testing and reporting are error-prone and redundant due to repeated, unnecessary requests and delayed or missed reactions to laboratory reports. Occurring errors may negatively affect the patient treatment process and clinical decision making. Evaluation on laboratory testing and Laboratory Information System (LIS) may explain the root cause to improve the testing process and enhance LIS in supporting the process. This paper discusses a new evaluation framework for LIS that encompasses the laboratory testing cycle and the socio-technical part of LIS. Literature review on discourses, dimensions and evaluation methods of laboratory testing and LIS. A critical appraisal of the Total Testing Process (TTP) and the human, organization, technology-fit factors (HOT-fit) evaluation frameworks was undertaken in order to identify error incident, its contributing factors and preventive action pertinent to laboratory testing process and LIS. A new evaluation framework for LIS using a comprehensive and socio-technical approach is outlined. Positive relationship between laboratory and clinical staff resulted in a smooth laboratory testing process, reduced errors and increased process efficiency whilst effective use of LIS streamlined the testing processes. The TTP-LIS framework could serve as an assessment as well as a problem-solving tool for the laboratory testing process and system. Copyright © 2016 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

Application of the FTA and ETA Method for Gas Hazard Identification for the Performance of Safety Systems in the Industrial Department

NASA Astrophysics Data System (ADS)

Ignac-Nowicka, Jolanta

2018-03-01

The paper analyzes the conditions of safe use of industrial gas systems and factors influencing gas hazards. Typical gas installation and its basic features have been characterized. The results of gas threat analysis in an industrial enterprise using FTA error tree method and ETA event tree method are presented. Compares selected methods of identifying hazards gas industry with respect to the scope of their use. The paper presents an analysis of two exemplary hazards: an industrial gas catastrophe (FTA) and an explosive gas explosion (ETA). In both cases, technical risks and human errors (human factor) were taken into account. The cause-effect relationships of hazards and their causes are presented in the form of diagrams in the drawings.

Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

PubMed

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

2012-12-01

Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Reducing measurement errors during functional capacity tests in elders.

PubMed

da Silva, Mariane Eichendorf; Orssatto, Lucas Bet da Rosa; Bezerra, Ewertton de Souza; Silva, Diego Augusto Santos; Moura, Bruno Monteiro de; Diefenthaeler, Fernando; Freitas, Cíntia de la Rocha

2018-06-01

Accuracy is essential to the validity of functional capacity measurements. To evaluate the error of measurement of functional capacity tests for elders and suggest the use of the technical error of measurement and credibility coefficient. Twenty elders (65.8 ± 4.5 years) completed six functional capacity tests that were simultaneously filmed and timed by four evaluators by means of a chronometer. A fifth evaluator timed the tests by analyzing the videos (reference data). The means of most evaluators for most tests were different from the reference (p < 0.05), except for two evaluators for two different tests. There were different technical error of measurement between tests and evaluators. The Bland-Altman test showed difference in the concordance of the results between methods. Short duration tests showed higher technical error of measurement than longer tests. In summary, tests timed by a chronometer underestimate the real results of the functional capacity. Difference between evaluators' reaction time and perception to determine the start and the end of the tests would justify the errors of measurement. Calculation of the technical error of measurement or the use of the camera can increase data validity.

76 FR 44010 - Medicare Program; Hospice Wage Index for Fiscal Year 2012; Correction

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-22

.... 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: July 15, 2011. Dawn L. Smalls... corrects technical errors that appeared in the notice of CMS ruling published in the Federal Register on... FR 26731), there were technical errors that are identified and corrected in the Correction of Errors...

Surgical timing after chemoradiotherapy for rectal cancer, analysis of technique (STARRCAT): results of a feasibility multi-centre randomized controlled trial.

PubMed

Foster, J D; Ewings, P; Falk, S; Cooper, E J; Roach, H; West, N P; Williams-Yesson, B A; Hanna, G B; Francis, N K

2016-10-01

The optimal time of rectal resection after long-course chemoradiotherapy (CRT) remains unclear. A feasibility study was undertaken for a multi-centre randomized controlled trial evaluating the impact of the interval after chemoradiotherapy on the technical complexity of surgery. Patients with rectal cancer were randomized to either a 6- or 12-week interval between CRT and surgery between June 2012 and May 2014 (ISRCTN registration number: 88843062). For blinded technical complexity assessment, the Observational Clinical Human Reliability Analysis technique was used to quantify technical errors enacted within video recordings of operations. Other measured outcomes included resection completeness, specimen quality, radiological down-staging, tumour cell density down-staging and surgeon-reported technical complexity. Thirty-one patients were enrolled: 15 were randomized to 6 and 16-12 weeks across 7 centres. Fewer eligible patients were identified than had been predicted. Of 23 patients who underwent resection, mean 12.3 errors were observed per case at 6 weeks vs. 10.7 at 12 weeks (p = 0.401). Other measured outcomes were similar between groups. The feasibility of measurement of operative performance of rectal cancer surgery as an endpoint was confirmed in this exploratory study. Recruitment of sufficient numbers of patients represented a challenge, and a proportion of patients did not proceed to resection surgery. These results suggest that interval after CRT may not substantially impact upon surgical technical performance.

Toward a Natural Speech Understanding System

DTIC Science & Technology

1989-10-01

WALTER J. SENUS Technical Director Directorate of Intelligence & Reconnaissance FOR THE COMMANDER JAMES W. HYDE III V Directorate of Plans & Programs ...applicable) Human Resources Laboratory F30602-81-C-0193 8 . ADDRESS (City, State, and ZIP Code) 10. SOURCE OF FUNDING NUMBERS PROGRAM PROJECT TASK WORK...error rates for distinctive words produced in isolation by a single speaker, and their simple programming requirements. Template-matching systems rank

Localizer Flight Technical Error Measurement and Uncertainty

DOT National Transportation Integrated Search

2011-09-18

Recent United States Federal Aviation Administration (FAA) wake turbulence research conducted at the John A. Volpe National Transportation Systems Center (The Volpe Center) has continued to monitor the representative localizer Flight Technical Error ...

Design and evaluation of an onboard computer-based information system for aircraft

NASA Technical Reports Server (NTRS)

Rouse, S. H.; Rouse, W. B.; Hammer, J. M.

1982-01-01

Information seeking by human operators of technical systems is considered. Types of information and forms of presentation are discussed and important issues reviewed. This broad discussion provides a framework within which flight management is considered. The design of an onboard computer-based information system for aircraft is discussed. The aiding possibilities of a computer-based system are emphasized. Results of an experimental evaluation of a prototype system are presented. It is concluded that a computer-based information system can substantially lessen the frequency of human errors.

Syntactical and Punctuation Errors: An Analysis of Technical Writing of University Students Science College, Taif University, KSA

ERIC Educational Resources Information Center

Alamin, Abdulamir; Ahmed, Sawsan

2012-01-01

Analyzing errors committed by second language learners during their first year of study at the University of Taif, can offer insights and knowledge of the learners' difficulties in acquiring technical English communication. With reference to the errors analyzed, the researcher found that the learners' failure to understand basic English grammar…

Flight Technical Error Analysis of the SATS Higher Volume Operations Simulation and Flight Experiments

NASA Technical Reports Server (NTRS)

Williams, Daniel M.; Consiglio, Maria C.; Murdoch, Jennifer L.; Adams, Catherine H.

2005-01-01

This paper provides an analysis of Flight Technical Error (FTE) from recent SATS experiments, called the Higher Volume Operations (HVO) Simulation and Flight experiments, which NASA conducted to determine pilot acceptability of the HVO concept for normal operating conditions. Reported are FTE results from simulation and flight experiment data indicating the SATS HVO concept is viable and acceptable to low-time instrument rated pilots when compared with today s system (baseline). Described is the comparative FTE analysis of lateral, vertical, and airspeed deviations from the baseline and SATS HVO experimental flight procedures. Based on FTE analysis, all evaluation subjects, low-time instrument-rated pilots, flew the HVO procedures safely and proficiently in comparison to today s system. In all cases, the results of the flight experiment validated the results of the simulation experiment and confirm the utility of the simulation platform for comparative Human in the Loop (HITL) studies of SATS HVO and Baseline operations.

The evidence of the rugoscopy effectiveness as a human identification method in patients submitted to rapid palatal expansion.

PubMed

Barbieri, Ana A; Scoralick, Raquel A; Naressi, Suely C M; Moraes, Mari E L; Daruge, Eduardo; Daruge, Eduardo

2013-01-01

The objective of this study was to demonstrate the effectiveness of rugoscopy as a human identification method, even when the patient is submitted to rapid palatal expansion, which in theory would introduce doubt. With this intent, the Rugoscopic Identity was obtained for each subject using the classification formula proposed by Santos based on the intra-oral casts made before and after treatment from patients who were subjected to palatal expansion. The casts were labeled with the patients' initials and randomly arranged for studying. The palatine rugae kept the same patterns in every case studied. The technical error of the intra-evaluator measurement provided a confidence interval of 95%, making rugoscopy a reliable identification method for patients who were submitted to rapid palatal expansion, because even in the presence of intra-oral changes owing to the use of palatal expanders, the palatine rugae retained the biological and technical requirements for the human identification process. © 2012 American Academy of Forensic Sciences.

U.S. Navy Fault-Tolerant Microcomputer.

DTIC Science & Technology

1982-07-01

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

A Bayesian method for using simulator data to enhance human error probabilities assigned by existing HRA methods

DOE PAGES

Groth, Katrina M.; Smith, Curtis L.; Swiler, Laura P.

2014-04-05

In the past several years, several international agencies have begun to collect data on human performance in nuclear power plant simulators [1]. This data provides a valuable opportunity to improve human reliability analysis (HRA), but there improvements will not be realized without implementation of Bayesian methods. Bayesian methods are widely used in to incorporate sparse data into models in many parts of probabilistic risk assessment (PRA), but Bayesian methods have not been adopted by the HRA community. In this article, we provide a Bayesian methodology to formally use simulator data to refine the human error probabilities (HEPs) assigned by existingmore » HRA methods. We demonstrate the methodology with a case study, wherein we use simulator data from the Halden Reactor Project to update the probability assignments from the SPAR-H method. The case study demonstrates the ability to use performance data, even sparse data, to improve existing HRA methods. Furthermore, this paper also serves as a demonstration of the value of Bayesian methods to improve the technical basis of HRA.« less

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

A comparison of human cadaver and augmented reality simulator models for straight laparoscopic colorectal skills acquisition training.

PubMed

LeBlanc, Fabien; Champagne, Bradley J; Augestad, Knut M; Neary, Paul C; Senagore, Anthony J; Ellis, Clyde N; Delaney, Conor P

2010-08-01

The aim of this study was to compare the human cadaver model with an augmented reality simulator for straight laparoscopic colorectal skills acquisition. Thirty-five sigmoid colectomies were performed on a cadaver (n = 7) or an augmented reality simulator (n = 28) during a laparoscopic training course. Prior laparoscopic colorectal experience was assessed. Objective structured technical skills assessment forms were completed by trainers and trainees independently. Groups were compared according to technical skills and events scores and satisfaction with training model. Prior laparoscopic experience was similar in both groups. For trainers and trainees, technical skills scores were considerably better on the simulator than on the cadaver. For trainers, generic events score was also considerably better on the simulator than on the cadaver. The main generic event occurring on both models was errors in the use of retraction. The main specific event occurring on both models was bowel perforation. Global satisfaction was better for the cadaver than for the simulator model (p < 0.001). The human cadaver model was more difficult but better appreciated than the simulator for laparoscopic sigmoid colectomy training. Simulator training followed by cadaver training can appropriately integrate simulators into the learning curve and maintain the benefits of both training methodologies. Published by Elsevier Inc.

Relationship between intraoperative non-technical performance and technical events in bariatric surgery.

PubMed

Fecso, A B; Kuzulugil, S S; Babaoglu, C; Bener, A B; Grantcharov, T P

2018-03-30

The operating theatre is a unique environment with complex team interactions, where technical and non-technical performance affect patient outcomes. The correlation between technical and non-technical performance, however, remains underinvestigated. The purpose of this study was to explore these interactions in the operating theatre. A prospective single-centre observational study was conducted at a tertiary academic medical centre. One surgeon and three fellows participated as main operators. All patients who underwent a laparoscopic Roux-en-Y gastric bypass and had the procedures captured using the Operating Room Black Box ® platform were included. Technical assessment was performed using the Objective Structured Assessment of Technical Skills and Generic Error Rating Tool instruments. For non-technical assessment, the Non-Technical Skills for Surgeons (NOTSS) and Scrub Practitioners' List of Intraoperative Non-Technical Skills (SPLINTS) tools were used. Spearman rank-order correlation and N-gram statistics were conducted. Fifty-six patients were included in the study and 90 procedural steps (gastrojejunostomy and jejunojejunostomy) were analysed. There was a moderate to strong correlation between technical adverse events (r s  = 0·417-0·687), rectifications (r s  = 0·380-0·768) and non-technical performance of the surgical and nursing teams (NOTSS and SPLINTS). N-gram statistics showed that after technical errors, events and prior rectifications, the staff surgeon and the scrub nurse exhibited the most positive non-technical behaviours, irrespective of operator (staff surgeon or fellow). This study demonstrated that technical and non-technical performances are related, on both an individual and a team level. Valuable data can be obtained around intraoperative errors, events and rectifications. © 2018 BJS Society Ltd Published by John Wiley & Sons Ltd.

75 FR 30756 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-02

.... 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical... technical errors that appeared in the supplementary proposed rule entitled ``Medicare Program; Supplemental... Doc. 2010-12567 filed May 21, 2010, there are technical and typographical errors that are identified...

Skeletal and body composition evaluation

NASA Technical Reports Server (NTRS)

Mazess, R. B.

1983-01-01

Research on radiation detectors for absorptiometry; analysis of errors affective single photon absorptiometry and development of instrumentation; analysis of errors affecting dual photon absorptiometry and development of instrumentation; comparison of skeletal measurements with other techniques; cooperation with NASA projects for skeletal evaluation in spaceflight (Experiment MO-78) and in laboratory studies with immobilized animals; studies of postmenopausal osteoporosis; organization of scientific meetings and workshops on absorptiometric measurement; and development of instrumentation for measurement of fluid shifts in the human body were performed. Instrumentation was developed that allows accurate and precise (2% error) measurements of mineral content in compact and trabecular bone and of the total skeleton. Instrumentation was also developed to measure fluid shifts in the extremities. Radiation exposure with those procedures is low (2-10 MREM). One hundred seventy three technical reports and one hundred and four published papers of studies from the University of Wisconsin Bone Mineral Lab are listed.

78 FR 69802 - Partner Vetting in USAID Assistance; Correction

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-21

... Vetting in USAID Assistance Rule. There was a technical error in the email address, provided in the Notice... public comments on the proposed rule. The technical error in the email address prevented comments that were submitted through that email address from being reviewable by USAID. As a result, USAID, with the...

75 FR 70013 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-16

... Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: November 9...: Correction notice. SUMMARY: This document corrects a technical error that appeared in the notice published in... of July 22, 2010 (75 FR 42836), there was a technical error that we are identifying and correcting in...

Radiology's Achilles' heel: error and variation in the interpretation of the Röntgen image.

PubMed

Robinson, P J

1997-11-01

The performance of the human eye and brain has failed to keep pace with the enormous technical progress in the first full century of radiology. Errors and variations in interpretation now represent the weakest aspect of clinical imaging. Those interpretations which differ from the consensus view of a panel of "experts" may be regarded as errors; where experts fail to achieve consensus, differing reports are regarded as "observer variation". Errors arise from poor technique, failures of perception, lack of knowledge and misjudgments. Observer variation is substantial and should be taken into account when different diagnostic methods are compared; in many cases the difference between observers outweighs the difference between techniques. Strategies for reducing error include attention to viewing conditions, training of the observers, availability of previous films and relevant clinical data, dual or multiple reporting, standardization of terminology and report format, and assistance from computers. Digital acquisition and display will probably not affect observer variation but the performance of radiologists, as measured by receiver operating characteristic (ROC) analysis, may be improved by computer-directed search for specific image features. Other current developments show that where image features can be comprehensively described, computer analysis can replace the perception function of the observer, whilst the function of interpretation can in some cases be performed better by artificial neural networks. However, computer-assisted diagnosis is still in its infancy and complete replacement of the human observer is as yet a remote possibility.

Technical Note: Millimeter precision in ultrasound based patient positioning: Experimental quantification of inherent technical limitations

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

Ballhausen, Hendrik, E-mail: hendrik.ballhausen@med.uni-muenchen.de; Hieber, Sheila; Li, Minglun

2014-08-15

Purpose: To identify the relevant technical sources of error of a system based on three-dimensional ultrasound (3D US) for patient positioning in external beam radiotherapy. To quantify these sources of error in a controlled laboratory setting. To estimate the resulting end-to-end geometric precision of the intramodality protocol. Methods: Two identical free-hand 3D US systems at both the planning-CT and the treatment room were calibrated to the laboratory frame of reference. Every step of the calibration chain was repeated multiple times to estimate its contribution to overall systematic and random error. Optimal margins were computed given the identified and quantified systematicmore » and random errors. Results: In descending order of magnitude, the identified and quantified sources of error were: alignment of calibration phantom to laser marks 0.78 mm, alignment of lasers in treatment vs planning room 0.51 mm, calibration and tracking of 3D US probe 0.49 mm, alignment of stereoscopic infrared camera to calibration phantom 0.03 mm. Under ideal laboratory conditions, these errors are expected to limit ultrasound-based positioning to an accuracy of 1.05 mm radially. Conclusions: The investigated 3D ultrasound system achieves an intramodal accuracy of about 1 mm radially in a controlled laboratory setting. The identified systematic and random errors require an optimal clinical tumor volume to planning target volume margin of about 3 mm. These inherent technical limitations do not prevent clinical use, including hypofractionation or stereotactic body radiation therapy.« less

2001 Research Reports NASA/ASEE Summer Faculty Fellowship Program

NASA Technical Reports Server (NTRS)

2001-01-01

This document is a collection of technical reports on research conducted by the participants in the 2001 NASA/ASEE Summer Faculty Fellowship Program at the Kennedy Space Center (KSC). Research areas are broad. Some of the topics addressed include: project management, space shuttle safety risks induced by human factor errors, body wearable computers as a feasible delivery system for 'work authorization documents', gas leak detection using remote sensing technologies, a history of the Kennedy Space Center, and design concepts for collabsible cyrogenic storage vessels.

Digital visual communications using a Perceptual Components Architecture

NASA Technical Reports Server (NTRS)

Watson, Andrew B.

1991-01-01

The next era of space exploration will generate extraordinary volumes of image data, and management of this image data is beyond current technical capabilities. We propose a strategy for coding visual information that exploits the known properties of early human vision. This Perceptual Components Architecture codes images and image sequences in terms of discrete samples from limited bands of color, spatial frequency, orientation, and temporal frequency. This spatiotemporal pyramid offers efficiency (low bit rate), variable resolution, device independence, error-tolerance, and extensibility.

Recommendations for reducing ambiguity in written procedures.

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

Matzen, Laura E.

Previous studies in the nuclear weapons complex have shown that ambiguous work instructions (WIs) and operating procedures (OPs) can lead to human error, which is a major cause for concern. This report outlines some of the sources of ambiguity in written English and describes three recommendations for reducing ambiguity in WIs and OPs. The recommendations are based on commonly used research techniques in the fields of linguistics and cognitive psychology. The first recommendation is to gather empirical data that can be used to improve the recommended word lists that are provided to technical writers. The second recommendation is to havemore » a review in which new WIs and OPs and checked for ambiguities and clarity. The third recommendation is to use self-paced reading time studies to identify any remaining ambiguities before the new WIs and OPs are put into use. If these three steps are followed for new WIs and OPs, the likelihood of human errors related to ambiguity could be greatly reduced.« less

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.

First-year Analysis of the Operating Room Black Box Study.

PubMed

Jung, James J; Jüni, Peter; Lebovic, Gerald; Grantcharov, Teodor

2018-06-18

To characterize intraoperative errors, events, and distractions, and measure technical skills of surgeons in minimally invasive surgery practice. Adverse events in the operating room (OR) are common contributors of morbidity and mortality in surgical patients. Adverse events often occur due to deviations in performance and environmental factors. Although comprehensive intraoperative data analysis and transparent disclosure have been advocated to better understand how to improve surgical safety, they have rarely been done. We conducted a prospective cohort study in 132 consecutive patients undergoing elective laparoscopic general surgery at an academic hospital during the first year after the definite implementation of a multiport data capture system called the OR Black Box to identify intraoperative errors, events, and distractions. Expert analysts characterized intraoperative distractions, errors, and events, and measured trainee involvement as main operator. Technical skills were compared, crude and risk-adjusted, among the attending surgeon and trainees. Auditory distractions occurred a median of 138 times per case [interquartile range (IQR) 96-190]. At least 1 cognitive distraction appeared in 84 cases (64%). Medians of 20 errors (IQR 14-36) and 8 events (IQR 4-12) were identified per case. Both errors and events occurred often in dissection and reconstruction phases of operation. Technical skills of residents were lower than those of the attending surgeon (P = 0.015). During elective laparoscopic operations, frequent intraoperative errors and events, variation in surgeons' technical skills, and a high amount of environmental distractions were identified using the OR Black Box.

Technical documentation challenges in aviation maintenance : a proceedings report.

DOT National Transportation Integrated Search

2012-11-01

The 2012 Technical Documentation workshop addressed both problems and solutions associated with technical : documentation for maintenance. These issues are known to cause errors, rework, maintenance delays, other : safety hazards, and FAA administrat...

Challenges of primate embryonic stem cell research.

PubMed

Bavister, Barry D; Wolf, Don P; Brenner, Carol A

2005-01-01

Embryonic stem (ES) cells hold great promise for treating degenerative diseases, including diabetes, Parkinson's, Alzheimer's, neural degeneration, and cardiomyopathies. This research is controversial to some because producing ES cells requires destroying embryos, which generally means human embryos. However, some of the surplus human embryos available from in vitro fertilization (IVF) clinics may have a high rate of genetic errors and therefore would be unsuitable for ES cell research. Although gross chromosome errors can readily be detected in ES cells, other anomalies such as mitochondrial DNA defects may have gone unrecognized. An insurmountable problem is that there are no human ES cells derived from in vivo-produced embryos to provide normal comparative data. In contrast, some monkey ES cell lines have been produced using in vivo-generated, normal embryos obtained from fertile animals; these can represent a "gold standard" for primate ES cells. In this review, we argue a need for strong research programs using rhesus monkey ES cells, conducted in parallel with studies on human ES and adult stem cells, to derive the maximum information about the biology of normal stem cells and to produce technical protocols for their directed differentiation into safe and functional replacement cells, tissues, and organs. In contrast, ES cell research using only human cell lines is likely to be incomplete, which could hinder research progress, and delay or diminish the effective application of ES cell technology to the treatment of human diseases.

Supporting the human life-raft in confronting the juggernaut of technology: Jens Rasmussen, 1961-1986.

PubMed

Kant, Vivek

2017-03-01

Jens Rasmussen's contribution to the field of human factors and ergonomics has had a lasting impact. Six prominent interrelated themes can be extracted from his research between 1961 and 1986. These themes form the basis of an engineering epistemology which is best manifested by his abstraction hierarchy. Further, Rasmussen reformulated technical reliability using systems language to enable a proper human-machine fit. To understand the concept of human-machine fit, he included the operator as a central component in the system to enhance system safety. This change resulted in the application of a qualitative and categorical approach for human-machine interaction design. Finally, Rasmussen's insistence on a working philosophy of systems design as being a joint responsibility of operators and designers provided the basis for averting errors and ensuring safe and correct system functioning. Copyright © 2016 Elsevier Ltd. All rights reserved.

Usability and feasibility of a tablet-based Decision-Support and Integrated Record-keeping (DESIRE) tool in the nurse management of hypertension in rural western Kenya.

PubMed

Vedanthan, Rajesh; Blank, Evan; Tuikong, Nelly; Kamano, Jemima; Misoi, Lawrence; Tulienge, Deborah; Hutchinson, Claire; Ascheim, Deborah D; Kimaiyo, Sylvester; Fuster, Valentin; Were, Martin C

2015-03-01

Mobile health (mHealth) applications have recently proliferated, especially in low- and middle-income countries, complementing task-redistribution strategies with clinical decision support. Relatively few studies address usability and feasibility issues that may impact success or failure of implementation, and few have been conducted for non-communicable diseases such as hypertension. To conduct iterative usability and feasibility testing of a tablet-based Decision Support and Integrated Record-keeping (DESIRE) tool, a technology intended to assist rural clinicians taking care of hypertension patients at the community level in a resource-limited setting in western Kenya. Usability testing consisted of "think aloud" exercises and "mock patient encounters" with five nurses, as well as one focus group discussion. Feasibility testing consisted of semi-structured interviews of five nurses and two members of the implementation team, and one focus group discussion with nurses. Content analysis was performed using both deductive codes and significant inductive codes. Critical incidents were identified and ranked according to severity. A cause-of-error analysis was used to develop corresponding design change suggestions. Fifty-seven critical incidents were identified in usability testing, 21 of which were unique. The cause-of-error analysis yielded 23 design change suggestions. Feasibility themes included barriers to implementation along both human and technical axes, facilitators to implementation, provider issues, patient issues and feature requests. This participatory, iterative human-centered design process revealed previously unaddressed usability and feasibility issues affecting the implementation of the DESIRE tool in western Kenya. In addition to well-known technical issues, we highlight the importance of human factors that can impact implementation of mHealth interventions. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Usability and Feasibility of a Tablet-Based Decision-Support and Integrated Record-Keeping (DESIRE) Tool in the Nurse Management of Hypertension in Rural Western Kenya

PubMed Central

Vedanthan, Rajesh; Blank, Evan; Tuikong, Nelly; Kamano, Jemima; Misoi, Lawrence; Tulienge, Deborah; Hutchinson, Claire; Ascheim, Deborah D.; Kimaiyo, Sylvester; Fuster, Valentin; Were, Martin C.

2015-01-01

Background Mobile health (mHealth) applications have recently proliferated, especially in low- and middle-income countries, complementing task-redistribution strategies with clinical decision support. Relatively few studies address usability and feasibility issues that may impact success or failure of implementation, and few have been conducted for non-communicable diseases such as hypertension. Objective To conduct iterative usability and feasibility testing of a tablet-based Decision Support and Integrated Record-keeping (DESIRE) tool, a technology intended to assist rural clinicians taking care of hypertension patients at the community level in a resource-limited setting in western Kenya. Methods Usability testing consisted of “think aloud” exercises and “mock patient encounters” with five nurses, as well as one focus group discussion. Feasibility testing consisted of semi-structured interviews of five nurses and two members of the implementation team, and one focus group discussion with nurses. Content analysis was performed using both deductive codes and significant inductive codes. Critical incidents were identified and ranked according to severity. A cause-of-error analysis was used to develop corresponding design change suggestions. Results Fifty-seven critical incidents were identified in usability testing, 21 of which were unique. The cause-of-error analysis yielded 23 design change suggestions. Feasibility themes included barriers to implementation along both human and technical axes, facilitators to implementation, provider issues, patient issues and feature requests. Conclusions This participatory, iterative human-centered design process revealed previously unaddressed usability and feasibility issues affecting the implementation of the DESIRE tool in western Kenya. In addition to well-known technical issues, we highlight the importance of human factors that can impact implementation of mHealth interventions. PMID:25612791

Application of Human Factors Methods to Design Healthcare Work Systems: Instance of the prevention of Adverse Drug Events.

PubMed

Marcilly, Romaric; Beuscart-Zephir, Marie-Catherine

2015-01-01

Human Factors (HF) methods are increasingly needed to support the design of new technologies in order to avoid that introducing those technologies into healthcare work systems induces use errors with potentially catastrophic consequences for the patients. This chapter illustrates the application of HF methods in developing two health technologies aiming at securing the hospital medication management process. Lessons learned from this project highlight the importance of (i) analyzing the work system in which the technology is intended to be implemented, (ii) involving end users in the design process and (iii) the intermediation role of HF between end users and scientific/technical experts.

High-Resolution X-Ray Telescopes

NASA Technical Reports Server (NTRS)

ODell, Stephen L.; Brissenden, Roger J.; Davis, William; Elsner, Ronald F.; Elvis, Martin; Freeman, Mark; Gaetz, Terry; Gorenstein, Paul; Gubarev, Mikhail V.

2010-01-01

Fundamental needs for future x-ray telescopes: a) Sharp images => excellent angular resolution. b) High throughput => large aperture areas. Generation-X optics technical challenges: a) High resolution => precision mirrors & alignment. b) Large apertures => lots of lightweight mirrors. Innovation needed for technical readiness: a) 4 top-level error terms contribute to image size. b) There are approaches to controlling those errors. Innovation needed for manufacturing readiness. Programmatic issues are comparably challenging.

76 FR 1669 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-11

... Areas Based on CBSA Labor Market Areas, we made technical and typographical errors in the composite rate... Based on CBSA Labor Market Areas, we made a technical error in the composite wage index for the nonurban... column, a. Second full paragraph, (1) Line 23, the figure ``1.181'' is corrected to read ``1.182.'' (2...

An improved estimator for the hydration of fat-free mass from in vivo measurements subject to additive technical errors.

PubMed

Kinnamon, Daniel D; Lipsitz, Stuart R; Ludwig, David A; Lipshultz, Steven E; Miller, Tracie L

2010-04-01

The hydration of fat-free mass, or hydration fraction (HF), is often defined as a constant body composition parameter in a two-compartment model and then estimated from in vivo measurements. We showed that the widely used estimator for the HF parameter in this model, the mean of the ratios of measured total body water (TBW) to fat-free mass (FFM) in individual subjects, can be inaccurate in the presence of additive technical errors. We then proposed a new instrumental variables estimator that accurately estimates the HF parameter in the presence of such errors. In Monte Carlo simulations, the mean of the ratios of TBW to FFM was an inaccurate estimator of the HF parameter, and inferences based on it had actual type I error rates more than 13 times the nominal 0.05 level under certain conditions. The instrumental variables estimator was accurate and maintained an actual type I error rate close to the nominal level in all simulations. When estimating and performing inference on the HF parameter, the proposed instrumental variables estimator should yield accurate estimates and correct inferences in the presence of additive technical errors, but the mean of the ratios of TBW to FFM in individual subjects may not.

Assessing team performance in the operating room: development and use of a "black-box" recorder and other tools for the intraoperative environment.

PubMed

Guerlain, Stephanie; Adams, Reid B; Turrentine, F Beth; Shin, Thomas; Guo, Hui; Collins, Stephen R; Calland, J Forrest

2005-01-01

The objective of this research was to develop a digital system to archive the complete operative environment along with the assessment tools for analysis of this data, allowing prospective studies of operative performance, intraoperative errors, team performance, and communication. Ability to study this environment will yield new insights, allowing design of systems to avoid preventable errors that contribute to perioperative complications. A multitrack, synchronized, digital audio-visual recording system (RATE tool) was developed to monitor intraoperative performance, including software to synchronize data and allow assignment of independent observational scores. Cases were scored for technical performance, participants' situational awareness (knowledge of critical information), and their comfort and satisfaction with the conduct of the procedure. Laparoscopic cholecystectomy (n = 10) was studied. Technical performance of the RATE tool was excellent. The RATE tool allowed real time, multitrack data collection of all aspects of the operative environment, while permitting digital recording of the objective assessment data in a time synchronized and annotated fashion during the procedure. The mean technical performance score was 73% +/- 28% of maximum (perfect) performance. Situational awareness varied widely among team members, with the attending surgeon typically the only team member having comprehensive knowledge of critical case information. The RATE tool allows prospective analysis of performance measures such as technical judgments, team performance, and communication patterns, offers the opportunity to conduct prospective intraoperative studies of human performance, and allows for postoperative discussion, review, and teaching. This study also suggests that gaps in situational awareness might be an underappreciated source of operative adverse events. Future uses of this system will aid teaching, failure or adverse event analysis, and intervention research.

Scientific and Technical Information. Handbook for Technical Report Preparation

DTIC Science & Technology

1991-05-31

31................. 16 Typography .......................................... 32.... ... ........ 16 Section Vill--REQUIREMENTS...marks. 16 AFDTCP 83-2 31 May 1991 SECTION VII ERRATA/ TYPOGRAPHY 31. ERRATA. Errors are normally corrected during proofing. If an error does-become... TYPOGRAPHY : a. Paper Size and Image Area. Paper size will be 8 1/2 by irc.• .,,.;od quality 50-pound white bond stock. The image area should be 6 1/2- by 8 3/4

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…

Navigating towards improved surgical safety using aviation-based strategies.

PubMed

Kao, Lillian S; Thomas, Eric J

2008-04-01

Safety practices in the aviation industry are being increasingly adapted to healthcare in an effort to reduce medical errors and patient harm. However, caution should be applied in embracing these practices because of limited experience in surgical disciplines, lack of rigorous research linking these practices to outcome, and fundamental differences between the two industries. Surgeons should have an in-depth understanding of the principles and data supporting aviation-based safety strategies before routinely adopting them. This paper serves as a review of strategies adapted to improve surgical safety, including the following: implementation of crew resource management in training operative teams; incorporation of simulation in training of technical and nontechnical skills; and analysis of contributory factors to errors using surveys, behavioral marker systems, human factors analysis, and incident reporting. Avenues and challenges for future research are also discussed.

Analysis of host response to bacterial infection using error model based gene expression microarray experiments

PubMed Central

Stekel, Dov J.; Sarti, Donatella; Trevino, Victor; Zhang, Lihong; Salmon, Mike; Buckley, Chris D.; Stevens, Mark; Pallen, Mark J.; Penn, Charles; Falciani, Francesco

2005-01-01

A key step in the analysis of microarray data is the selection of genes that are differentially expressed. Ideally, such experiments should be properly replicated in order to infer both technical and biological variability, and the data should be subjected to rigorous hypothesis tests to identify the differentially expressed genes. However, in microarray experiments involving the analysis of very large numbers of biological samples, replication is not always practical. Therefore, there is a need for a method to select differentially expressed genes in a rational way from insufficiently replicated data. In this paper, we describe a simple method that uses bootstrapping to generate an error model from a replicated pilot study that can be used to identify differentially expressed genes in subsequent large-scale studies on the same platform, but in which there may be no replicated arrays. The method builds a stratified error model that includes array-to-array variability, feature-to-feature variability and the dependence of error on signal intensity. We apply this model to the characterization of the host response in a model of bacterial infection of human intestinal epithelial cells. We demonstrate the effectiveness of error model based microarray experiments and propose this as a general strategy for a microarray-based screening of large collections of biological samples. PMID:15800204

A consideration of the nature of work and the consequences for the human-oriented design of production and products.

PubMed

Bubb, Heiner

2006-07-01

In this article, it is shown that human work can be understood as a process of creating order, and that order can be seen as a form of information. Since information can be considered as negative entropy, work is associated with energy consumption. Therefore, it is important to investigate the nature of human necessities in more detail in order to meet the desire for comfort through the efficient application of energy. Temporary increases of information cause accelerated increases in entropy. This explains the appearance of living organisms, and the historic development of increasingly complex technology. Through technical progress, repetitive human work is being replaced by automation, so that primarily creative work remains. Now the question arises of how much creative work a human can manage. In addition, one goal of automation should be the reduction of human errors, but in doing so, an optimal balance should be found between supporting the operator both during normal procedures and during unforeseen circumstances.

ALICE Expert System

NASA Astrophysics Data System (ADS)

Ionita, C.; Carena, F.

2014-06-01

The ALICE experiment at CERN employs a number of human operators (shifters), who have to make sure that the experiment is always in a state compatible with taking Physics data. Given the complexity of the system and the myriad of errors that can arise, this is not always a trivial task. The aim of this paper is to describe an expert system that is capable of assisting human shifters in the ALICE control room. The system diagnoses potential issues and attempts to make smart recommendations for troubleshooting. At its core, a Prolog engine infers whether a Physics or a technical run can be started based on the current state of the underlying sub-systems. A separate C++ component queries certain SMI objects and stores their state as facts in a Prolog knowledge base. By mining the data stored in different system logs, the expert system can also diagnose errors arising during a run. Currently the system is used by the on-call experts for faster response times, but we expect it to be adopted as a standard tool by regular shifters during the next data taking period.

AgRISTARS. Preliminary technical results review of FY81 experiments, volume 2: Fiscal year 1981/1982 "corn and soybeans pilot" experiment

NASA Technical Reports Server (NTRS)

1981-01-01

The performance of the technology exhibited significant proportion estimation errors, specifically, high mean error in both corn and soybeans area estimation. The data systems, technical approaches, and data assessment of the pilot experiment were reviewed. Results of proportion estimations procedure performance evaluations, and sensitivity evaluations are presented. The role of the pilot experiment in foreign technology development is discussed.

Correction of a Technical Error in the Golf Swing: Error Amplification Versus Direct Instruction.

PubMed

Milanese, Chiara; Corte, Stefano; Salvetti, Luca; Cavedon, Valentina; Agostini, Tiziano

2016-01-01

Performance errors drive motor learning for many tasks. The authors' aim was to determine which of two strategies, method of amplification of error (MAE) or direct instruction (DI), would be more beneficial for error correction during a full golfing swing with a driver. Thirty-four golfers were randomly assigned to one of three training conditions (MAE, DI, and control). Participants were tested in a practice session in which each golfer performed 7 pretraining trials, 6 training-intervention trials, and 7 posttraining trials; and a retention test after 1 week. An optoeletronic motion capture system was used to measure the kinematic parameters of each golfer's performance. Results showed that MAE is an effective strategy for correcting the technical errors leading to a rapid improvement in performance. These findings could have practical implications for sport psychology and physical education because, while practice is obviously necessary for improving learning, the efficacy of the learning process is essential in enhancing learners' motivation and sport enjoyment.

Error Pattern Analysis Applied to Technical Writing: An Editor's Guide for Writers.

ERIC Educational Resources Information Center

Monagle, E. Brette

The use of error pattern analysis can reduce the time and money spent on editing and correcting manuscripts. What is required is noting, classifying, and keeping a frequency count of errors. First an editor should take a typical page of writing and circle each error. After the editor has done a sufficiently large number of pages to identify an…

A Systematic Approach to Error Free Telemetry

DTIC Science & Technology

2017-06-28

A SYSTEMATIC APPROACH TO ERROR FREE TELEMETRY 412TW-TIM-17-03 DISTRIBUTION A: Approved for public release. Distribution is...Systematic Approach to Error-Free Telemetry) was submitted by the Commander, 412th Test Wing, Edwards AFB, California 93524. Prepared by...Technical Information Memorandum 3. DATES COVERED (From - Through) February 2016 4. TITLE AND SUBTITLE A Systematic Approach to Error-Free

Do Errors on Classroom Reading Tasks Slow Growth in Reading? Technical Report No. 404.

ERIC Educational Resources Information Center

Anderson, Richard C.; And Others

A pervasive finding from research on teaching and classroom learning is that a low rate of error on classroom tasks is associated with large year to year gains in achievement, particularly for reading in the primary grades. The finding of a negative relationship between error rate, especially rate of oral reading errors, and gains in reading…

The Public Understanding of Error in Educational Assessment

ERIC Educational Resources Information Center

Gardner, John

2013-01-01

Evidence from recent research suggests that in the UK the public perception of errors in national examinations is that they are simply mistakes; events that are preventable. This perception predominates over the more sophisticated technical view that errors arise from many sources and create an inevitable variability in assessment outcomes. The…

Strength conditions for the elastic structures with a stress error

NASA Astrophysics Data System (ADS)

Matveev, A. D.

2017-10-01

As is known, the constraints (strength conditions) for the safety factor of elastic structures and design details of a particular class, e.g. aviation structures are established, i.e. the safety factor values of such structures should be within the given range. It should be noted that the constraints are set for the safety factors corresponding to analytical (exact) solutions of elasticity problems represented for the structures. Developing the analytical solutions for most structures, especially irregular shape ones, is associated with great difficulties. Approximate approaches to solve the elasticity problems, e.g. the technical theories of deformation of homogeneous and composite plates, beams and shells, are widely used for a great number of structures. Technical theories based on the hypotheses give rise to approximate (technical) solutions with an irreducible error, with the exact value being difficult to be determined. In static calculations of the structural strength with a specified small range for the safety factors application of technical (by the Theory of Strength of Materials) solutions is difficult. However, there are some numerical methods for developing the approximate solutions of elasticity problems with arbitrarily small errors. In present paper, the adjusted reference (specified) strength conditions for the structural safety factor corresponding to approximate solution of the elasticity problem have been proposed. The stress error estimation is taken into account using the proposed strength conditions. It has been shown that, to fulfill the specified strength conditions for the safety factor of the given structure corresponding to an exact solution, the adjusted strength conditions for the structural safety factor corresponding to an approximate solution are required. The stress error estimation which is the basis for developing the adjusted strength conditions has been determined for the specified strength conditions. The adjusted strength conditions presented by allowable stresses are suggested. Adjusted strength conditions make it possible to determine the set of approximate solutions, whereby meeting the specified strength conditions. Some examples of the specified strength conditions to be satisfied using the technical (by the Theory of Strength of Materials) solutions and strength conditions have been given, as well as the examples of stress conditions to be satisfied using approximate solutions with a small error.

What does "Diversity" Mean for Public Engagement in Science? A New Metric for Innovation Ecosystem Diversity.

PubMed

Özdemir, Vural; Springer, Simon

2018-03-01

Diversity is increasingly at stake in early 21st century. Diversity is often conceptualized across ethnicity, gender, socioeconomic status, sexual preference, and professional credentials, among other categories of difference. These are important and relevant considerations and yet, they are incomplete. Diversity also rests in the way we frame questions long before answers are sought. Such diversity in the framing (epistemology) of scientific and societal questions is important for they influence the types of data, results, and impacts produced by research. Errors in the framing of a research question, whether in technical science or social science, are known as type III errors, as opposed to the better known type I (false positives) and type II errors (false negatives). Kimball defined "error of the third kind" as giving the right answer to the wrong problem. Raiffa described the type III error as correctly solving the wrong problem. Type III errors are upstream or design flaws, often driven by unchecked human values and power, and can adversely impact an entire innovation ecosystem, waste money, time, careers, and precious resources by focusing on the wrong or incorrectly framed question and hypothesis. Decades may pass while technology experts, scientists, social scientists, funding agencies and management consultants continue to tackle questions that suffer from type III errors. We propose a new diversity metric, the Frame Diversity Index (FDI), based on the hitherto neglected diversities in knowledge framing. The FDI would be positively correlated with epistemological diversity and technological democracy, and inversely correlated with prevalence of type III errors in innovation ecosystems, consortia, and knowledge networks. We suggest that the FDI can usefully measure (and prevent) type III error risks in innovation ecosystems, and help broaden the concepts and practices of diversity and inclusion in science, technology, innovation and society.

A Unified Approach to Measurement Error and Missing Data: Details and Extensions

ERIC Educational Resources Information Center

Blackwell, Matthew; Honaker, James; King, Gary

2017-01-01

We extend a unified and easy-to-use approach to measurement error and missing data. In our companion article, Blackwell, Honaker, and King give an intuitive overview of the new technique, along with practical suggestions and empirical applications. Here, we offer more precise technical details, more sophisticated measurement error model…

Human Error: A Concept Analysis

NASA Technical Reports Server (NTRS)

Hansen, Frederick D.

2007-01-01

Human error is the subject of research in almost every industry and profession of our times. This term is part of our daily language and intuitively understood by most people however, it would be premature to assume that everyone's understanding of human error s the same. For example, human error is used to describe the outcome or consequence of human action, the causal factor of an accident, deliberate violations,a nd the actual action taken by a human being. As a result, researchers rarely agree on the either a specific definition or how to prevent human error. The purpose of this article is to explore the specific concept of human error using Concept Analysis as described by Walker and Avant (1995). The concept of human error is examined as currently used in the literature of a variety of industries and professions. Defining attributes and examples of model, borderline, and contrary cases are described. The antecedents and consequences of human error are also discussed and a definition of human error is offered.

Challenges in leveraging existing human performance data for quantifying the IDHEAS HRA method

DOE PAGES

Liao, Huafei N.; Groth, Katrina; Stevens-Adams, Susan

2015-07-29

Our article documents an exploratory study for collecting and using human performance data to inform human error probability (HEP) estimates for a new human reliability analysis (HRA) method, the IntegrateD Human Event Analysis System (IDHEAS). The method was based on cognitive models and mechanisms underlying human behaviour and employs a framework of 14 crew failure modes (CFMs) to represent human failures typical for human performance in nuclear power plant (NPP) internal, at-power events [1]. A decision tree (DT) was constructed for each CFM to assess the probability of the CFM occurring in different contexts. Data needs for IDHEAS quantification aremore » discussed. Then, the data collection framework and process is described and how the collected data were used to inform HEP estimation is illustrated with two examples. Next, five major technical challenges are identified for leveraging human performance data for IDHEAS quantification. Furthermore, these challenges reflect the data needs specific to IDHEAS. More importantly, they also represent the general issues with current human performance data and can provide insight for a path forward to support HRA data collection, use, and exchange for HRA method development, implementation, and validation.« less

Does teaching non-technical skills to medical students improve those skills and simulated patient outcome?

PubMed

Hagemann, Vera; Herbstreit, Frank; Kehren, Clemens; Chittamadathil, Jilson; Wolfertz, Sandra; Dirkmann, Daniel; Kluge, Annette; Peters, Jürgen

2017-03-29

The purpose of this study is to evaluate the effects of a tailor-made, non-technical skills seminar on medical student's behaviour, attitudes, and performance during simulated patient treatment. Seventy-seven students were randomized to either a non-technical skills seminar (NTS group, n=43) or a medical seminar (control group, n=34). The human patient simulation was used as an evaluation tool. Before the seminars, all students performed the same simulated emergency scenario to provide baseline measurements. After the seminars, all students were exposed to a second scenario, and behavioural markers for evaluating their non-technical skills were rated. Furthermore, teamwork-relevant attitudes were measured before and after the scenarios, and perceived stress was measured following each simulation. All simulations were also evaluated for various medical endpoints. Non-technical skills concerning situation awareness (p<.01, r=0.5) and teamwork (p<.01, r=0.45) improved from simulation I to II in the NTS group. Decision making improved in both groups (NTS: p<.01, r=0.39; control: p<.01, r=0.46). The attitude 'handling errors' improved significantly in the NTS group (p<.05, r=0.34). Perceived stress decreased from simulation I to II in both groups. Medical endpoints and patients´ outcome did not differ significantly between the groups in simulation II. This study highlights the effectiveness of a single brief seminar on non-technical skills to improve student's non-technical skills. In a next step, to improve student's handling of emergencies and patient outcomes, non-technical skills seminars should be accompanied by exercises and more broadly embedded in the medical school curriculum.

Understanding adverse events: human factors.

PubMed Central

Reason, J

1995-01-01

(1) Human rather than technical failures now represent the greatest threat to complex and potentially hazardous systems. This includes healthcare systems. (2) Managing the human risks will never be 100% effective. Human fallibility can be moderated, but it cannot be eliminated. (3) Different error types have different underlying mechanisms, occur in different parts of the organisation, and require different methods of risk management. The basic distinctions are between: Slips, lapses, trips, and fumbles (execution failures) and mistakes (planning or problem solving failures). Mistakes are divided into rule based mistakes and knowledge based mistakes. Errors (information-handling problems) and violations (motivational problems) Active versus latent failures. Active failures are committed by those in direct contact with the patient, latent failures arise in organisational and managerial spheres and their adverse effects may take a long time to become evident. (4) Safety significant errors occur at all levels of the system, not just at the sharp end. Decisions made in the upper echelons of the organisation create the conditions in the workplace that subsequently promote individual errors and violations. Latent failures are present long before an accident and are hence prime candidates for principled risk management. (5) Measures that involve sanctions and exhortations (that is, moralistic measures directed to those at the sharp end) have only very limited effectiveness, especially so in the case of highly trained professionals. (6) Human factors problems are a product of a chain of causes in which the individual psychological factors (that is, momentary inattention, forgetting, etc) are the last and least manageable links. Attentional "capture" (preoccupation or distraction) is a necessary condition for the commission of slips and lapses. Yet, its occurrence is almost impossible to predict or control effectively. The same is true of the factors associated with forgetting. States of mind contributing to error are thus extremely difficult to manage; they can happen to the best of people at any time. (7) People do not act in isolation. Their behaviour is shaped by circumstances. The same is true for errors and violations. The likelihood of an unsafe act being committed is heavily influenced by the nature of the task and by the local workplace conditions. These, in turn, are the product of "upstream" organisational factors. Great gains in safety can ve achieved through relatively small modifications of equipment and workplaces. (8) Automation and increasing advanced equipment do not cure human factors problems, they merely relocate them. In contrast, training people to work effectively in teams costs little, but has achieved significant enhancements of human performance in aviation. (9) Effective risk management depends critically on a confidential and preferable anonymous incident monitoring system that records the individual, task, situational, and organisational factors associated with incidents and near misses. (10) Effective risk management means the simultaneous and targeted deployment of limited remedial resources at different levels of the system: the individual or team, the task, the situation, and the organisation as a whole. PMID:10151618

Final Rule for Technical Amendments to the Highway and Nonroad Diesel Regulations

EPA Pesticide Factsheets

This action corrects errors and omissions from the previous rules, makes minor changes to the regulations to assist entities with regulatory compliance, and makes technical amendments that resulted from discussions with various diesel stakeholders.

Technical editing of research reports in biomedical journals.

PubMed

Wager, Elizabeth; Middleton, Philippa

2008-10-08

Most journals try to improve their articles by technical editing processes such as proof-reading, editing to conform to 'house styles', grammatical conventions and checking accuracy of cited references. Despite the considerable resources devoted to technical editing, we do not know whether it improves the accessibility of biomedical research findings or the utility of articles. This is an update of a Cochrane methodology review first published in 2003. To assess the effects of technical editing on research reports in peer-reviewed biomedical journals, and to assess the level of accuracy of references to these reports. We searched The Cochrane Library Issue 2, 2007; MEDLINE (last searched July 2006); EMBASE (last searched June 2007) and checked relevant articles for further references. We also searched the Internet and contacted researchers and experts in the field. Prospective or retrospective comparative studies of technical editing processes applied to original research articles in biomedical journals, as well as studies of reference accuracy. Two review authors independently assessed each study against the selection criteria and assessed the methodological quality of each study. One review author extracted the data, and the second review author repeated this. We located 32 studies addressing technical editing and 66 surveys of reference accuracy. Only three of the studies were randomised controlled trials. A 'package' of largely unspecified editorial processes applied between acceptance and publication was associated with improved readability in two studies and improved reporting quality in another two studies, while another study showed mixed results after stricter editorial policies were introduced. More intensive editorial processes were associated with fewer errors in abstracts and references. Providing instructions to authors was associated with improved reporting of ethics requirements in one study and fewer errors in references in two studies, but no difference was seen in the quality of abstracts in one randomised controlled trial. Structuring generally improved the quality of abstracts, but increased their length. The reference accuracy studies showed a median citation error rate of 38% and a median quotation error rate of 20%. Surprisingly few studies have evaluated the effects of technical editing rigorously. However there is some evidence that the 'package' of technical editing used by biomedical journals does improve papers. A substantial number of references in biomedical articles are cited or quoted inaccurately.

Human-system Interfaces to Automatic Systems: Review Guidance and Technical Basis

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

OHara, J.M.; Higgins, J.C.

Automation has become ubiquitous in modern complex systems and commercial nuclear power plants are no exception. Beyond the control of plant functions and systems, automation is applied to a wide range of additional functions including monitoring and detection, situation assessment, response planning, response implementation, and interface management. Automation has become a 'team player' supporting plant personnel in nearly all aspects of plant operation. In light of the increasing use and importance of automation in new and future plants, guidance is needed to enable the NRC staff to conduct safety reviews of the human factors engineering (HFE) aspects of modern automation.more » The objective of the research described in this report was to develop guidance for reviewing the operator's interface with automation. We first developed a characterization of the important HFE aspects of automation based on how it is implemented in current systems. The characterization included five dimensions: Level of automation, function of automation, modes of automation, flexibility of allocation, and reliability of automation. Next, we reviewed literature pertaining to the effects of these aspects of automation on human performance and the design of human-system interfaces (HSIs) for automation. Then, we used the technical basis established by the literature to develop design review guidance. The guidance is divided into the following seven topics: Automation displays, interaction and control, automation modes, automation levels, adaptive automation, error tolerance and failure management, and HSI integration. In addition, we identified insights into the automaton design process, operator training, and operations.« less

Handling the Difficulties of Technical School Students in the Construction and Interpretation of Graphic Representations

ERIC Educational Resources Information Center

Marinos, Andreas

2010-01-01

In this work, an attempt is made to evaluate the errors that have to do with the interpretation and construction of graphic representations. Although the students are studying in the second year of technical high school (secondary education), i.e. in schools with an emphasis in technical subjects (post junior secondary), it is observed that they…

Refractive error characteristics of early and advanced presbyopic individuals.

DOT National Transportation Integrated Search

1977-07-01

The frequency and distribution of ocular refractive errors among middle-aged and older people were obtained from a nonclinical population holding a variety of blue-collar, clerical, and technical jobs. The 422 individuals ranged in age from 35 to 69 ...

A Review of Research on Error Detection. Technical Report No. 540.

ERIC Educational Resources Information Center

Meyer, Linda A.

A review was conducted of the research on error detection studies completed with children, adolescents, and young adults to determine at what age children begin to detect errors in texts. The studies were grouped according to the subjects' ages. The focus of the review was on the following aspects of each study: the hypothesis that guided the…

The Birch Street Irregulars: mysteries found and resolved in the AAVSO data archives

NASA Astrophysics Data System (ADS)

Beck, Sara J.; Saladyga, Michael; Mattei, Janet A.

As they evaluate AAVSO data, AAVSO technical staff members run across several kinds of errors. This paper takes a humorous and Sherlock Holmes-style look at some of the most common kinds of errors detected, from observers recording the wrong Julian Date, misidentifying stars, transposing entries on the observer form, to garden-variety data entry 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.

Follow-up of negative MRI-targeted prostate biopsies: when are we missing cancer?

PubMed

Gold, Samuel A; Hale, Graham R; Bloom, Jonathan B; Smith, Clayton P; Rayn, Kareem N; Valera, Vladimir; Wood, Bradford J; Choyke, Peter L; Turkbey, Baris; Pinto, Peter A

2018-05-21

Multiparametric magnetic resonance imaging (mpMRI) has improved clinicians' ability to detect clinically significant prostate cancer (csPCa). Combining or fusing these images with the real-time imaging of transrectal ultrasound (TRUS) allows urologists to better sample lesions with a targeted biopsy (Tbx) leading to the detection of greater rates of csPCa and decreased rates of low-risk PCa. In this review, we evaluate the technical aspects of the mpMRI-guided Tbx procedure to identify possible sources of error and provide clinical context to a negative Tbx. A literature search was conducted of possible reasons for false-negative TBx. This includes discussion on false-positive mpMRI findings, termed "PCa mimics," that may incorrectly suggest high likelihood of csPCa as well as errors during Tbx resulting in inexact image fusion or biopsy needle placement. Despite the strong negative predictive value associated with Tbx, concerns of missed disease often remain, especially with MR-visible lesions. This raises questions about what to do next after a negative Tbx result. Potential sources of error can arise from each step in the targeted biopsy process ranging from "PCa mimics" or technical errors during mpMRI acquisition to failure to properly register MRI and TRUS images on a fusion biopsy platform to technical or anatomic limits on needle placement accuracy. A better understanding of these potential pitfalls in the mpMRI-guided Tbx procedure will aid interpretation of a negative Tbx, identify areas for improving technical proficiency, and improve both physician understanding of negative Tbx and patient-management options.

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

Determination of facial symmetry in unilateral cleft lip and palate patients from three-dimensional data: technical report and assessment of measurement errors.

PubMed

Nkenke, Emeka; Lehner, Bernhard; Kramer, Manuel; Haeusler, Gerd; Benz, Stefanie; Schuster, Maria; Neukam, Friedrich W; Vairaktaris, Eleftherios G; Wurm, Jochen

2006-03-01

To assess measurement errors of a novel technique for the three-dimensional determination of the degree of facial symmetry in patients suffering from unilateral cleft lip and palate malformations. Technical report, reliability study. Cleft Lip and Palate Center of the University of Erlangen-Nuremberg, Erlangen, Germany. The three-dimensional facial surface data of five 10-year-old unilateral cleft lip and palate patients were subjected to the analysis. Distances, angles, surface areas, and volumes were assessed twice. Calculations were made for method error, intraclass correlation coefficient, and repeatability of the measurements of distances, angles, surface areas, and volumes. The method errors were less than 1 mm for distances and less than 1.5 degrees for angles. The intraclass correlation coefficients showed values greater than .90 for all parameters. The repeatability values were comparable for cleft and noncleft sides. The small method errors, high intraclass correlation coefficients, and comparable repeatability values for cleft and noncleft sides reveal that the new technique is appropriate for clinical use.

Comparison of technique errors of intraoral radiographs taken on film v photostimulable phosphor (PSP) plates.

PubMed

Zhang, Wenjian; Huynh, Carolyn P; Abramovitch, Kenneth; Leon, Inga-Lill K; Arvizu, Liliana

2012-06-01

The objective of this study was to compare the technical errors of intraoral radiographs exposed on film v photostimulable phosphor (PSP) plates. The intraoral radiographic images exposed on phantoms from preclinical practical exams of dental and dental hygiene students were used. Each exam consisted of 10 designated periapical and bitewing views. A total of 107 film sets and 122 PSP sets were evaluated for technique errors, including placement, elongation, foreshortening, overlapping, cone cut, receptor bending, density, mounting, dot in apical area, and others. Some errors were further subcategorized as minor, major, or remake depending on the severity. The percentages of radiographs with various errors were compared between film and PSP by the Fisher's Exact Test. Compared with film, there was significantly less PSP foreshortening, elongation, and bending errors, but significantly more placement and overlapping errors. Using a wrong sized receptor due to the similarity of the color of the package sleeves is a unique PSP error. Optimum image quality is attainable with PSP plates as well as film. When switching from film to a PSP digital environment, more emphasis is necessary for placing the PSP plates, especially those with excessive packet edge, and then correcting the corresponding angulation for the beam alignment. Better design for improving intraoral visibility and easy identification of different sized PSP will improve the clinician's technical performance with this receptor.

Understanding human management of automation errors

PubMed Central

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

2013-01-01

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

Understanding human management of automation errors.

PubMed

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

2014-01-01

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

Human operator response to error-likely situations in complex engineering systems

NASA Technical Reports Server (NTRS)

Morris, Nancy M.; Rouse, William B.

1988-01-01

The causes of human error in complex systems are examined. First, a conceptual framework is provided in which two broad categories of error are discussed: errors of action, or slips, and errors of intention, or mistakes. Conditions in which slips and mistakes might be expected to occur are identified, based on existing theories of human error. Regarding the role of workload, it is hypothesized that workload may act as a catalyst for error. Two experiments are presented in which humans' response to error-likely situations were examined. Subjects controlled PLANT under a variety of conditions and periodically provided subjective ratings of mental effort. A complex pattern of results was obtained, which was not consistent with predictions. Generally, the results of this research indicate that: (1) humans respond to conditions in which errors might be expected by attempting to reduce the possibility of error, and (2) adaptation to conditions is a potent influence on human behavior in discretionary situations. Subjects' explanations for changes in effort ratings are also explored.

Human error and human factors engineering in health care.

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.

Analysis of human factors effects on the safety of transporting radioactive waste materials: Technical report

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

Abkowitz, M.D.; Abkowitz, S.B.; Lepofsky, M.

1989-04-01

This report examines the extent of human factors effects on the safety of transporting radioactive waste materials. It is seen principally as a scoping effort, to establish whether there is a need for DOE to undertake a more formal approach to studying human factors in radioactive waste transport, and if so, logical directions for that program to follow. Human factors effects are evaluated on driving and loading/transfer operations only. Particular emphasis is placed on the driving function, examining the relationship between human error and safety as it relates to the impairment of driver performance. Although multi-modal in focus, the widespreadmore » availability of data and previous literature on truck operations resulted in a primary study focus on the trucking mode from the standpoint of policy development. In addition to the analysis of human factors accident statistics, the report provides relevant background material on several policies that have been instituted or are under consideration, directed at improving human reliability in the transport sector. On the basis of reported findings, preliminary policy areas are identified. 71 refs., 26 figs., 5 tabs.« less

Applications of integrated human error identification techniques on the chemical cylinder change task.

PubMed

Cheng, Ching-Min; Hwang, Sheue-Ling

2015-03-01

This paper outlines the human error identification (HEI) techniques that currently exist to assess latent human errors. Many formal error identification techniques have existed for years, but few have been validated to cover latent human error analysis in different domains. This study considers many possible error modes and influential factors, including external error modes, internal error modes, psychological error mechanisms, and performance shaping factors, and integrates several execution procedures and frameworks of HEI techniques. The case study in this research was the operational process of changing chemical cylinders in a factory. In addition, the integrated HEI method was used to assess the operational processes and the system's reliability. It was concluded that the integrated method is a valuable aid to develop much safer operational processes and can be used to predict human error rates on critical tasks in the plant. Copyright © 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.

44 CFR 67.6 - Basis of appeal.

Code of Federal Regulations, 2014 CFR

2014-10-01

... technically incorrect. Because scientific and technical correctness is often a matter of degree rather than...), appellants are required to demonstrate that alternative methods or applications result in more correct... due to error in application of hydrologic, hydraulic or other methods or use of inferior data in...

44 CFR 67.6 - Basis of appeal.

Code of Federal Regulations, 2012 CFR

2012-10-01

... technically incorrect. Because scientific and technical correctness is often a matter of degree rather than...), appellants are required to demonstrate that alternative methods or applications result in more correct... due to error in application of hydrologic, hydraulic or other methods or use of inferior data in...

44 CFR 67.6 - Basis of appeal.

Code of Federal Regulations, 2013 CFR

2013-10-01

... technically incorrect. Because scientific and technical correctness is often a matter of degree rather than...), appellants are required to demonstrate that alternative methods or applications result in more correct... due to error in application of hydrologic, hydraulic or other methods or use of inferior data in...

44 CFR 67.6 - Basis of appeal.

Code of Federal Regulations, 2011 CFR

2011-10-01

... technically incorrect. Because scientific and technical correctness is often a matter of degree rather than...), appellants are required to demonstrate that alternative methods or applications result in more correct... due to error in application of hydrologic, hydraulic or other methods or use of inferior data in...

Measurement standards for interdisciplinary medical rehabilitation.

PubMed

Johnston, M V; Keith, R A; Hinderer, S R

1992-12-01

Rehabilitation must address problems inherent in the measurement of human function and health-related quality of life, as well as problems in diagnosis and measurement of impairment. This educational document presents an initial set of standards to be used as guidelines for development and use of measurement and evaluation procedures and instruments for interdisciplinary, health-related rehabilitation. Part I covers general measurement principles and technical standards, beginning with validity, the central consideration for use of measures. Subsequent sections focus on reliability and errors of measurement, norms and scaling, development of measures, and technical manuals and guides. Part II covers principles and standards for use of measures. General principles of application of measures in practice are discussed first, followed by standards to protect persons being measured and then by standards for administrative applications. Many explanations, examples, and references are provided to help professionals understand measurement principles. Improved measurement will ensure the basis of rehabilitation as a science and nourish its success as a clinical service.

Cost effective nuclear commercial grade dedication

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

Maletz, J.J.; Marston, M.J.

1991-01-01

This paper describes a new computerized database method to create/edit/view specification technical data sheets (mini-specifications) for procurement of spare parts for nuclear facility maintenance and to develop information that could support possible future facility life extension efforts. This method may reduce cost when compared with current manual methods. The use of standardized technical data sheets (mini-specifications) for items of the same category improves efficiency. This method can be used for a variety of tasks, including: Nuclear safety-related procurement; Non-safety related procurement; Commercial grade item procurement/dedication; Evaluation of replacement items. This program will assist the nuclear facility in upgrading its procurementmore » activities consistent with the recent NUMARC Procurement Initiative. Proper utilization of the program will assist the user in assuring that the procured items are correct for the applications, provide data to assist in detecting fraudulent materials, minimize human error in withdrawing database information, improve data retrievability, improve traceability, and reduce long-term procurement costs.« less

Free-Inertial and Damped-Inertial Navigation Mechanization and Error Equations

DTIC Science & Technology

1975-04-18

AD-A014 356 FREE-INERTIAL AND DAMPED-INERTIAL NAVIGATION MECHANIZATION AND ERROR EQUATIONS Warren G. Heller Analytic Sciences Corporation Prepared...IHI IL JI -J THE ANALYTIC SCIENCES CORPORATION TR-312-1-1 FREE-INERTIAL AND DAMPED-INERTIAL NAViGATION MECHANIZATION AND ERROR EQUATIONS Ap~ril 18...PERIOO COVC/REO Fr-,- 1wer l and Dmped-Inertial Navigation Technical Mechanization and Error Equations 8/20-73 - 8/20/74 S. PjLtFORJ4djNjOjO, REPORT

Human error in airway facilities.

DOT National Transportation Integrated Search

2001-01-01

This report examines human errors in Airway Facilities (AF) with the intent of preventing these errors from being : passed on to the new Operations Control Centers. To effectively manage errors, they first have to be identified. : Human factors engin...

Latent human error analysis and efficient improvement strategies by fuzzy TOPSIS in aviation maintenance tasks.

PubMed

Chiu, Ming-Chuan; Hsieh, Min-Chih

2016-05-01

The purposes of this study were to develop a latent human error analysis process, to explore the factors of latent human error in aviation maintenance tasks, and to provide an efficient improvement strategy for addressing those errors. First, we used HFACS and RCA to define the error factors related to aviation maintenance tasks. Fuzzy TOPSIS with four criteria was applied to evaluate the error factors. Results show that 1) adverse physiological states, 2) physical/mental limitations, and 3) coordination, communication, and planning are the factors related to airline maintenance tasks that could be addressed easily and efficiently. This research establishes a new analytic process for investigating latent human error and provides a strategy for analyzing human error using fuzzy TOPSIS. Our analysis process complements shortages in existing methodologies by incorporating improvement efficiency, and it enhances the depth and broadness of human error analysis methodology. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

75 FR 37815 - Submission for OMB review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-30

... agencies to annually report error rate measures. Section 2 of the Improper Payments Information Act... requires preparation and submission of a report of errors occurring in the administration of Child Care... the annual Agency Financial Report (AFR) and will provide information necessary to offer technical...

Erratum to Dynamic stresses, Coulomb failure, and remote triggering and to Surface wave potential for triggering tectonic (nonvolcanic) tremor

USGS Publications Warehouse

Hill, David P.

2012-01-01

Hill (2008) and Hill (2010) contain two technical errors: (1) a missing factor of 2 for computed Love‐wave amplitudes, and (2) a sign error in the off‐diagonal elements in the Euler rotation matrix.

Modeling for Military Operational Medicine Scientific and Technical Objectives

DTIC Science & Technology

2005-09-01

measurements and less error in interpreting the measurements since the sensor units are placed directly under armor ; and (3) new material that matches the...more accurate measurements and less error in interpreting the measurements, since the sensor units are placed directly under armor ; and (3) new

The Unfortunate Human Factor: A Selective History of Human Factors for Technical Communicators.

ERIC Educational Resources Information Center

Johnson, Robert R.

1994-01-01

Reviews moments in the history of human factors that are especially relevant to the field of technical communications. Discusses human factors research that is applicable to technical communications. Focuses on qualitative usability research, minimalism, and human activity interface design. (HB)

Automated work packages architecture: An initial set of human factors and instrumentation and controls requirements

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

Agarwal, Vivek; Oxstrand, Johanna H.; Le Blanc, Katya L.

The work management process in current fleets of national nuclear power plants is so highly dependent on large technical staffs and quality of work instruction, i.e., paper-based, that this puts nuclear energy at somewhat of a long-term economic disadvantage and increase the possibility of human errors. Technologies like mobile portable devices and computer-based procedures can play a key role in improving the plant work management process, thereby increasing productivity and decreasing cost. Automated work packages are a fundamentally an enabling technology for improving worker productivity and human performance in nuclear power plants work activities because virtually every plant work activitymore » is accomplished using some form of a work package. As part of this year’s research effort, automated work packages architecture is identified and an initial set of requirements identified, that are essential and necessary for implementation of automated work packages in nuclear power plants.« less

Reliability of anthropometric measurements in European preschool children: the ToyBox-study.

PubMed

De Miguel-Etayo, P; Mesana, M I; Cardon, G; De Bourdeaudhuij, I; Góźdź, M; Socha, P; Lateva, M; Iotova, V; Koletzko, B V; Duvinage, K; Androutsos, O; Manios, Y; Moreno, L A

2014-08-01

The ToyBox-study aims to develop and test an innovative and evidence-based obesity prevention programme for preschoolers in six European countries: Belgium, Bulgaria, Germany, Greece, Poland and Spain. In multicentre studies, anthropometric measurements using standardized procedures that minimize errors in the data collection are essential to maximize reliability of measurements. The aim of this paper is to describe the standardization process and reliability (intra- and inter-observer) of height, weight and waist circumference (WC) measurements in preschoolers. All technical procedures and devices were standardized and centralized training was given to the fieldworkers. At least seven children per country participated in the intra- and inter-observer reliability testing. Intra-observer technical error ranged from 0.00 to 0.03 kg for weight and from 0.07 to 0.20 cm for height, with the overall reliability being above 99%. A second training was organized for WC due to low reliability observed in the first training. Intra-observer technical error for WC ranged from 0.12 to 0.71 cm during the first training and from 0.05 to 1.11 cm during the second training, and reliability above 92% was achieved. Epidemiological surveys need standardized procedures and training of researchers to reduce measurement error. In the ToyBox-study, very good intra- and-inter-observer agreement was achieved for all anthropometric measurements performed. © 2014 World Obesity.

An Analysis of Oral Reading Errors and Its Implications for Improvement of Reading Instruction. Technical Report No. 50.

ERIC Educational Resources Information Center

Au, Kathryn H.

The oral reading errors of 15 second graders were analyzed to find out if strategies used by good and poor readers could be differentiated. Patterns of errors were identified, and it was found that good readers often used context cues, while poor readers relied heavily on visual-phonic information. It was also possible to identify good and poor…

Information systems and human error in the lab.

PubMed

Bissell, Michael G

2004-01-01

Health system costs in clinical laboratories are incurred daily due to human error. Indeed, a major impetus for automating clinical laboratories has always been the opportunity it presents to simultaneously reduce cost and improve quality of operations by decreasing human error. But merely automating these processes is not enough. To the extent that introduction of these systems results in operators having less practice in dealing with unexpected events or becoming deskilled in problemsolving, however new kinds of error will likely appear. Clinical laboratories could potentially benefit by integrating findings on human error from modern behavioral science into their operations. Fully understanding human error requires a deep understanding of human information processing and cognition. Predicting and preventing negative consequences requires application of this understanding to laboratory operations. Although the occurrence of a particular error at a particular instant cannot be absolutely prevented, human error rates can be reduced. The following principles are key: an understanding of the process of learning in relation to error; understanding the origin of errors since this knowledge can be used to reduce their occurrence; optimal systems should be forgiving to the operator by absorbing errors, at least for a time; although much is known by industrial psychologists about how to write operating procedures and instructions in ways that reduce the probability of error, this expertise is hardly ever put to use in the laboratory; and a feedback mechanism must be designed into the system that enables the operator to recognize in real time that an error has occurred.

76 FR 4549 - Testing of Certain High Production Volume Chemicals; Second Group of Chemicals; Technical Correction

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-26

... Testing of Certain High Production Volume Chemicals; Second Group of Chemicals; Technical Correction... production volume (HPV) chemical substances to obtain screening level data for health and environmental effects and chemical fate. This document is being issued to correct a typographical error concerning the...

78 FR 34264 - Technical Corrections to the HIPAA Privacy, Security, and Enforcement Rules

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-07

...-AA03 Technical Corrections to the HIPAA Privacy, Security, and Enforcement Rules AGENCY: Office for... corrections address certain inadvertent errors and omissions in the HIPAA Privacy, Security, and Enforcement... (HHS or ``the Department'') published a final rule to implement changes to the HIPAA Privacy, Security...

Additional Final Area Designations and Technical Amendment for the 2012 Annual Fine Particle Standard Established in 2012 - Mar 2015

EPA Pesticide Factsheets

EPA is establishing or revising initial area designations and a technical amendment to correct an inadvertent error in the initial designation for one area for the 2012 annual national ambient air quality standards for fine particle pollution.

Research in Automatic Russian-English Scientific and Technical Lexicography. Final Report.

ERIC Educational Resources Information Center

Wayne State Univ., Detroit, MI.

Techniques of reversing English-Russian scientific and technical dictionaries into Russian-English versions through semi-automated compilation are described. Sections on manual and automatic processing discuss pre- and post-editing, the task program, updater (correction of errors and revision by specialist in a given field), the system employed…

77 FR 32400 - Fenamidone; Pesticide Tolerance; Technical Amendment

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-01

...., of the preamble, the text correctly listed the tolerance level for the commodity ``strawberry'' at 0... the tolerance level for ``strawberry'' at 0.15. This technical amendment corrects that error. III. Why... revising the entry for ``Strawberry'' in paragraph (d) to read as follows: Sec. [emsp14]180.579 Fenamidone...

76 FR 41178 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-13

... Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: July 7, 2011...), HHS. ACTION: Correction of proposed rule. SUMMARY: This document corrects technical errors that... explanation of publishing such Tables on the Internet), reflect an error in the calculation of the...

Integrity management of offshore structures and its implication on computation of structural action effects and resistance

NASA Astrophysics Data System (ADS)

Moan, T.

2017-12-01

An overview of integrity management of offshore structures, with emphasis on the oil and gas energy sector, is given. Based on relevant accident experiences and means to control the associated risks, accidents are categorized from a technical-physical as well as human and organizational point of view. Structural risk relates to extreme actions as well as structural degradation. Risk mitigation measures, including adequate design criteria, inspection, repair and maintenance as well as quality assurance and control of engineering processes, are briefly outlined. The current status of risk and reliability methodology to aid decisions in the integrity management is briefly reviewed. Finally, the need to balance the uncertainties in data, methods and computational efforts and the cautious use and quality assurance and control in applying high fidelity methods to avoid human errors, is emphasized, and with a plea to develop both high fidelity as well as efficient, simplified methods for design.

EUV via hole pattern fidelity enhancement through novel resist and post-litho plasma treatment

NASA Astrophysics Data System (ADS)

Yaegashi, Hidetami; Koike, Kyohei; Fonseca, Carlos; Yamashita, Fumiko; Kaushik, Kumar; Morikita, Shinya; Ito, Kiyohito; Yoshimura, Shota; Timoshkov, Vadim; Maslow, Mark; Jee, Tae Kwon; Reijnen, Liesbeth; Choi, Peter; Feng, Mu; Spence, Chris; Schoofs, Stijn

2018-03-01

Extreme UV(EUV) technology must be potential solution for sustainable scaling, and its adoption in high volume manufacturing(HVM) is getting realistic more and more. This technology has a wide capability to mitigate various technical problem in Multi-patterning (LELELE) for via hole patterning with 193-i. It induced local pattern fidelity error such like CDU, CER, Pattern placement error. Exactly, EUV must be desirable scaling-driving tool, however, specific technical issue, named RLS (Resolution-LER-Sensitivity) triangle, obvious remaining issue. In this work, we examined hole patterning sensitizing (Lower dose approach) utilizing hole patterning restoration technique named "CD-Healing" as post-Litho. treatment.

Stochastic Models of Human Errors

NASA Technical Reports Server (NTRS)

Elshamy, Maged; Elliott, Dawn M. (Technical Monitor)

2002-01-01

Humans play an important role in the overall reliability of engineering systems. More often accidents and systems failure are traced to human errors. Therefore, in order to have meaningful system risk analysis, the reliability of the human element must be taken into consideration. Describing the human error process by mathematical models is a key to analyzing contributing factors. Therefore, the objective of this research effort is to establish stochastic models substantiated by sound theoretic foundation to address the occurrence of human errors in the processing of the space shuttle.

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.

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.

An Error Analysis for the Finite Element Method Applied to Convection Diffusion Problems.

DTIC Science & Technology

1981-03-01

D TFhG-]NOLOGY k 4b 00 \\" ) ’b Technical Note BN-962 AN ERROR ANALYSIS FOR THE FINITE ELEMENT METHOD APPLIED TO CONVECTION DIFFUSION PROBLEM by I...Babu~ka and W. G. Szym’czak March 1981 V.. UNVI I Of- ’i -S AN ERROR ANALYSIS FOR THE FINITE ELEMENT METHOD P. - 0 w APPLIED TO CONVECTION DIFFUSION ...AOAO98 895 MARYLAND UNIVYCOLLEGE PARK INST FOR PHYSICAL SCIENCE--ETC F/G 12/I AN ERROR ANALYIS FOR THE FINITE ELEMENT METHOD APPLIED TO CONV..ETC (U

Engineering Technical Review Planning Briefing

NASA Technical Reports Server (NTRS)

Gardner, Terrie

2012-01-01

The general topics covered in the engineering technical planning briefing are 1) overviews of NASA, Marshall Space Flight Center (MSFC), and Engineering, 2) the NASA Systems Engineering(SE) Engine and its implementation , 3) the NASA Project Life Cycle, 4) MSFC Technical Management Branch Services in relation to the SE Engine and the Project Life Cycle , 5) Technical Reviews, 6) NASA Human Factor Design Guidance , and 7) the MSFC Human Factors Team. The engineering technical review portion of the presentation is the primary focus of the overall presentation and will address the definition of a design review, execution guidance, the essential stages of a technical review, and the overall review planning life cycle. Examples of a technical review plan content, review approaches, review schedules, and the review process will be provided and discussed. The human factors portion of the presentation will focus on the NASA guidance for human factors. Human factors definition, categories, design guidance, and human factor specialist roles will be addressed. In addition, the NASA Systems Engineering Engine description, definition, and application will be reviewed as background leading into the NASA Project Life Cycle Overview and technical review planning discussion.

The contributions of human factors on human error in Malaysia aviation maintenance industries

NASA Astrophysics Data System (ADS)

Padil, H.; Said, M. N.; Azizan, A.

2018-05-01

Aviation maintenance is a multitasking activity in which individuals perform varied tasks under constant pressure to meet deadlines as well as challenging work conditions. These situational characteristics combined with human factors can lead to various types of human related errors. The primary objective of this research is to develop a structural relationship model that incorporates human factors, organizational factors, and their impact on human errors in aviation maintenance. Towards that end, a questionnaire was developed which was administered to Malaysian aviation maintenance professionals. Structural Equation Modelling (SEM) approach was used in this study utilizing AMOS software. Results showed that there were a significant relationship of human factors on human errors and were tested in the model. Human factors had a partial effect on organizational factors while organizational factors had a direct and positive impact on human errors. It was also revealed that organizational factors contributed to human errors when coupled with human factors construct. This study has contributed to the advancement of knowledge on human factors effecting safety and has provided guidelines for improving human factors performance relating to aviation maintenance activities and could be used as a reference for improving safety performance in the Malaysian aviation maintenance companies.

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 Reliability and the Cost of Doing Business

NASA Technical Reports Server (NTRS)

DeMott, Diana

2014-01-01

Most businesses recognize that people will make mistakes and assume errors are just part of the cost of doing business, but does it need to be? Companies with high risk, or major consequences, should consider the effect of human error. In a variety of industries, Human Errors have caused costly failures and workplace injuries. These have included: airline mishaps, medical malpractice, administration of medication and major oil spills have all been blamed on human error. A technique to mitigate or even eliminate some of these costly human errors is the use of Human Reliability Analysis (HRA). Various methodologies are available to perform Human Reliability Assessments that range from identifying the most likely areas for concern to detailed assessments with human error failure probabilities calculated. Which methodology to use would be based on a variety of factors that would include: 1) how people react and act in different industries, and differing expectations based on industries standards, 2) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 3) type and availability of data and 4) how the industry views risk & reliability influences ( types of emergencies, contingencies and routine tasks versus cost based concerns). The Human Reliability Assessments should be the first step to reduce, mitigate or eliminate the costly mistakes or catastrophic failures. Using Human Reliability techniques to identify and classify human error risks allows a company more opportunities to mitigate or eliminate these risks and prevent costly failures.

Navigation errors encountered using weather-mapping radar for helicopter IFR guidance to oil rigs

NASA Technical Reports Server (NTRS)

Phillips, J. D.; Bull, J. S.; Hegarty, D. M.; Dugan, D. C.

1980-01-01

In 1978 a joint NASA-FAA helicopter flight test was conducted to examine the use of weather-mapping radar for IFR guidance during landing approaches to oil rig helipads. The following navigation errors were measured: total system error, radar-range error, radar-bearing error, and flight technical error. Three problem areas were identified: (1) operational problems leading to pilot blunders, (2) poor navigation to the downwind final approach point, and (3) pure homing on final approach. Analysis of these problem areas suggests improvement in the radar equipment, approach procedure, and pilot training, and gives valuable insight into the development of future navigation aids to serve the off-shore oil industry.

Human Reliability and the Cost of Doing Business

NASA Technical Reports Server (NTRS)

DeMott, D. L.

2014-01-01

Human error cannot be defined unambiguously in advance of it happening, it often becomes an error after the fact. The same action can result in a tragic accident for one situation or a heroic action given a more favorable outcome. People often forget that we employ humans in business and industry for the flexibility and capability to change when needed. In complex systems, operations are driven by their specifications of the system and the system structure. People provide the flexibility to make it work. Human error has been reported as being responsible for 60%-80% of failures, accidents and incidents in high-risk industries. We don't have to accept that all human errors are inevitable. Through the use of some basic techniques, many potential human error events can be addressed. There are actions that can be taken to reduce the risk of human error.

77 FR 1129 - Revisions to Test Methods and Testing Regulations

Federal Register 2010, 2011, 2012, 2013, 2014

2012-01-09

...This action proposes editorial and technical corrections necessary for source testing of emissions and operations. The revisions include the addition of alternative equipment and methods as well as corrections to technical and typographical errors. We also solicit public comment on potential changes to the current procedures for determining emission stratification.

Analysis of professional malpractice claims in implant dentistry in Italy from insurance company technical reports, 2006 to 2010.

PubMed

Pinchi, Vilma; Varvara, Giuseppe; Pradella, Francesco; Focardi, Martina; Donati, Michele D; Norelli, Gianaristide

2014-01-01

The aim of the study was to analyze the characteristics of implant dentistry claims in Italy based on insurance company technical reports for malpractice claims. One hundred twenty-one technical reports of cases of professional malpractice in implant dentistry between 2006 and 2010 were included in the study. Data included the sex and age of the patient and dentist, the kind of negligence claimed, and the damages awarded as a consequence of the alleged misconduct. Of the cases examined in this study, 9.9% went to court. The patients were female in 73.6% of the cases. Most of the technical errors were committed during implant insertion (82.6%). In 50.4% of cases, the technical error involved the surrounding structures, such as damage to the inferior alveolar nerve (32.2%) or the lingual nerve (2.5%), invasion of the maxillary sinus (9.1%), or pulpal dental necrosis in adjacent teeth (6.6%). Incomplete clinical documentation was apparent in 54.5% of cases. In 9.9% of cases, a civil suit had already been filed before a visit, and medicolegal advice from the insurance expert had been procured. The discrepancy between the total number of cases examined and those that went to court indicates that implant malpractice claims in Italy are most often settled out of court. The large number of intraoperative errors seen and the high proportion of injuries to surrounding structures suggest that implant dentists would benefit from further specific training. Also, clinical documentation vital to a defense against any claims relating to professional misconduct was incomplete or absent in more than half of the cases.

76 FR 34633 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-14

....773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance... errors in the proposed rule entitled ``Medicare Program; Proposed Changes to the Hospital Inpatient...-9644 of May 5, 2011 (76 FR 25788), there were a number of technical and typographical errors that are...

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

PubMed Central

Jahangiri, Mehdi; Hoboubi, Naser; Rostamabadi, Akbar; Keshavarzi, Sareh; Hosseini, Ali Akbar

2015-01-01

Background A permit to work (PTW) is a formal written system to control certain types of work which are identified as potentially hazardous. However, human error in PTW processes can lead to an accident. Methods This cross-sectional, descriptive study was conducted to estimate the probability of human errors in PTW processes in a chemical plant in Iran. In the first stage, through interviewing the personnel and studying the procedure in the plant, the PTW process was analyzed using the hierarchical task analysis technique. In doing so, PTW was considered as a goal and detailed tasks to achieve the goal were analyzed. In the next step, the standardized plant analysis risk-human (SPAR-H) reliability analysis method was applied for estimation of human error probability. Results The mean probability of human error in the PTW system was estimated to be 0.11. The highest probability of human error in the PTW process was related to flammable gas testing (50.7%). Conclusion The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided. PMID:27014485

Teamwork and error in the operating room: analysis of skills and roles.

PubMed

Catchpole, K; Mishra, A; Handa, A; McCulloch, P

2008-04-01

To analyze the effects of surgical, anesthetic, and nursing teamwork skills on technical outcomes. The value of team skills in reducing adverse events in the operating room is presently receiving considerable attention. Current work has not yet identified in detail how the teamwork and communication skills of surgeons, anesthetists, and nurses affect the course of an operation. Twenty-six laparoscopic cholecystectomies and 22 carotid endarterectomies were studied using direct observation methods. For each operation, teams' skills were scored for the whole team, and for nursing, surgical, and anesthetic subteams on 4 dimensions (leadership and management [LM]; teamwork and cooperation; problem solving and decision making; and situation awareness). Operating time, errors in surgical technique, and other procedural problems and errors were measured as outcome parameters for each operation. The relationships between teamwork scores and these outcome parameters within each operation were examined using analysis of variance and linear regression. Surgical (F(2,42) = 3.32, P = 0.046) and anesthetic (F(2,42) = 3.26, P = 0.048) LM had significant but opposite relationships with operating time in each operation: operating time increased significantly with higher anesthetic but decreased with higher surgical LM scores. Errors in surgical technique had a strong association with surgical situation awareness (F(2,42) = 7.93, P < 0.001) in each operation. Other procedural problems and errors were related to the intraoperative LM skills of the nurses (F(5,1) = 3.96, P = 0.027). Detailed analysis of team interactions and dimensions is feasible and valuable, yielding important insights into relationships between nontechnical skills, technical performance, and operative duration. These results support the concept that interventions designed to improve teamwork and communication may have beneficial effects on technical performance and patient outcome.

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.

Prediction of human errors by maladaptive changes in event-related brain networks.

PubMed

Eichele, Tom; Debener, Stefan; Calhoun, Vince D; Specht, Karsten; Engel, Andreas K; Hugdahl, Kenneth; von Cramon, D Yves; Ullsperger, Markus

2008-04-22

Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve approximately 30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations.

Prediction of human errors by maladaptive changes in event-related brain networks

PubMed Central

Eichele, Tom; Debener, Stefan; Calhoun, Vince D.; Specht, Karsten; Engel, Andreas K.; Hugdahl, Kenneth; von Cramon, D. Yves; Ullsperger, Markus

2008-01-01

Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve ≈30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations. PMID:18427123

Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

NASA Technical Reports Server (NTRS)

Wiegmann, Douglas A.; Rantanen, Eas M.

2003-01-01

The modus operandi in addressing human error in aviation systems is predominantly that of technological interventions or fixes. Such interventions exhibit considerable variability both in terms of sophistication and application. Some technological interventions address human error directly while others do so only indirectly. Some attempt to eliminate the occurrence of errors altogether whereas others look to reduce the negative consequences of these errors. In any case, technological interventions add to the complexity of the systems and may interact with other system components in unforeseeable ways and often create opportunities for novel human errors. Consequently, there is a need to develop standards for evaluating the potential safety benefit of each of these intervention products so that resources can be effectively invested to produce the biggest benefit to flight safety as well as to mitigate any adverse ramifications. The purpose of this project was to help define the relationship between human error and technological interventions, with the ultimate goal of developing a set of standards for evaluating or measuring the potential benefits of new human error fixes.

Applying lessons learned to enhance human performance and reduce human error for ISS operations

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

Nelson, W.R.

1999-01-01

A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy{close_quote}s Idaho National Engineering and Environmental Laboratory (INEEL) is developing a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper will describe previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS. {copyright} {ital 1999 American Institute of Physics.}« less

Applying lessons learned to enhance human performance and reduce human error for ISS operations

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

Nelson, W.R.

1998-09-01

A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.« less

High definition video teaching module for learning neck dissection.

PubMed

Mendez, Adrian; Seikaly, Hadi; Ansari, Kal; Murphy, Russell; Cote, David

2014-03-25

Video teaching modules are proven effective tools for enhancing student competencies and technical skills in the operating room. Integration into post-graduate surgical curricula, however, continues to pose a challenge in modern surgical education. To date, video teaching modules for neck dissection have yet to be described in the literature. To develop and validate an HD video-based teaching module (HDVM) to help instruct post-graduate otolaryngology trainees in performing neck dissection. This prospective study included 6 intermediate to senior otolaryngology residents. All consented subjects first performed a control selective neck dissection. Subjects were then exposed to the video teaching module. Following a washout period, a repeat procedure was performed. Recordings of the both sets of neck dissections were de-identified and reviewed by an independent evaluator and scored using the Observational Clinical Human Reliability Assessment (OCHRA) system. In total 91 surgical errors were made prior to the HDVM and 41 after exposure, representing a 55% decrease in error occurrence. The two groups were found to be significantly different. Similarly, 66 and 24 staff takeover events occurred pre and post HDVM exposure, respectively, representing a statistically significant 64% decrease. HDVM is a useful adjunct to classical surgical training. Residents performed significantly less errors following exposure to the HD-video module. Similarly, significantly less staff takeover events occurred following exposure to the HDVM.

A Study on Generic Representation of Skeletal Remains Replication of Prehistoric Burial

NASA Astrophysics Data System (ADS)

Shao, C.-W.; Chiu, H.-L.; Chang, S.-K.

2015-08-01

Generic representation of skeletal remains from burials consists of three dimensions which include physical anthropologists, replication technicians, and promotional educators. For the reason that archaeological excavation is irreversible and disruptive, detail documentation and replication technologies are surely needed for many purposes. Unearthed bones during the process of 3D digital scanning need to go through reverse procedure, 3D scanning, digital model superimposition, rapid prototyping, mould making, and the integrated errors generated from the presentation of colours and textures are important issues for the presentation of replicate skeleton remains among professional decisions conducted by physical anthropologists, subjective determination of makers, and the expectations of viewers. This study presents several cases and examines current issues on display and replication technologies for human skeletal remains of prehistoric burials. This study documented detail colour changes of human skeleton over time for the reference of reproduction. The tolerance errors of quantification and required technical qualification is acquired according to the precision of 3D scanning, the specification requirement of rapid prototyping machine, and the mould making process should following the professional requirement for physical anthropological study. Additionally, the colorimeter is adopted to record and analyse the "colour change" of the human skeletal remains from wet to dry condition. Then, the "colure change" is used to evaluate the "real" surface texture and colour presentation of human skeletal remains, and to limit the artistic presentation among the human skeletal remains reproduction. The"Lingdao man No.1", is a well preserved burial of early Neolithic period (8300 B.P.) excavated from Liangdao-Daowei site, Matsu, Taiwan , as the replicating object for this study. In this study, we examined the reproduction procedures step by step for ensuring the surface texture and colour of the replica matches the real human skeletal remains when discovered. The "colour change" of the skeleton documented and quantified in this study could be the reference for the future study and educational exhibition of human skeletal remain reproduction.

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

Integration of MSFC Usability Lab with Usability Testing

NASA Technical Reports Server (NTRS)

Cheng, Yiwei; Richardson, Sally

2010-01-01

As part of the Stage Analysis Branch, human factors engineering plays an important role in relating humans to the systems of hardware and structure designs of the new launch vehicle. While many branches are involved in the technical aspects of creating a launch vehicle, human factors connects humans to the scientific systems with the goal of improving operational performance and safety while reducing operational error and damage to the hardware. Human factors engineers use physical and computerized models to visualize possible areas for improvements to ensure human accessibility to components requiring maintenance and that the necessary maintenance activities can be accomplished with minimal risks to human and hardware. Many methods of testing are used to fulfill this goal, such as physical mockups, computerized visualization, and usability testing. In this analysis, a usability test is conducted to test how usable a website is to users who are and are not familiar with it. The testing is performed using participants and Morae software to record and analyze the results. This analysis will be a preliminary test of the usability lab in preparation for use in new spacecraft programs, NASA Enterprise, or other NASA websites. The usability lab project is divided into two parts: integration of the usability lab and a preliminary test of the usability lab.

Human errors and violations in computer and information security: the viewpoint of network administrators and security specialists.

PubMed

Kraemer, Sara; Carayon, Pascale

2007-03-01

This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.

Intervention strategies for the management of human error

NASA Technical Reports Server (NTRS)

Wiener, Earl L.

1993-01-01

This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.

Exploring Reactions to Pilot Reliability Certification and Changing Attitudes on the Reduction of Errors

ERIC Educational Resources Information Center

Boedigheimer, Dan

2010-01-01

Approximately 70% of aviation accidents are attributable to human error. The greatest opportunity for further improving aviation safety is found in reducing human errors in the cockpit. The purpose of this quasi-experimental, mixed-method research was to evaluate whether there was a difference in pilot attitudes toward reducing human error in the…

Evaluating a medical error taxonomy.

PubMed

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

2002-01-01

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

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

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

Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu; Harris, Kendra M.; Ford, Eric

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface,more » (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.« less

Sleep quality, posttraumatic stress, depression, and human errors in train drivers: a population-based nationwide study in South Korea.

PubMed

Jeon, Hong Jin; Kim, Ji-Hae; Kim, Bin-Na; Park, Seung Jin; Fava, Maurizio; Mischoulon, David; Kang, Eun-Ho; Roh, Sungwon; Lee, Dongsoo

2014-12-01

Human error is defined as an unintended error that is attributable to humans rather than machines, and that is important to avoid to prevent accidents. We aimed to investigate the association between sleep quality and human errors among train drivers. Cross-sectional. Population-based. A sample of 5,480 subjects who were actively working as train drivers were recruited in South Korea. The participants were 4,634 drivers who completed all questionnaires (response rate 84.6%). None. The Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Impact of Event Scale-Revised (IES-R), the State-Trait Anxiety Inventory (STAI), and the Korean Occupational Stress Scale (KOSS). Of 4,634 train drivers, 349 (7.5%) showed more than one human error per 5 y. Human errors were associated with poor sleep quality, higher PSQI total scores, short sleep duration at night, and longer sleep latency. Among train drivers with poor sleep quality, those who experienced severe posttraumatic stress showed a significantly higher number of human errors than those without. Multiple logistic regression analysis showed that human errors were significantly associated with poor sleep quality and posttraumatic stress, whereas there were no significant associations with depression, trait and state anxiety, and work stress after adjusting for age, sex, education years, marital status, and career duration. Poor sleep quality was found to be associated with more human errors in train drivers, especially in those who experienced severe posttraumatic stress. © 2014 Associated Professional Sleep Societies, LLC.

77 FR 1889 - Drivers of CMVs: Restricting the Use of Cellular Phones; Technical Amendment

Federal Register 2010, 2011, 2012, 2013, 2014

2012-01-12

... DEPARTMENT OF TRANSPORTATION Federal Motor Carrier Safety Administration 49 CFR Part 391 [Docket No. FMCSA-2010-0096] RIN 2126-AB29 Drivers of CMVs: Restricting the Use of Cellular Phones; Technical... Cellular Phones final rule (76 FR 75470) had a clerical error in Sec. 391.15(f)(1) that stated ``paragraph...

Analyzing human errors in flight mission operations

NASA Technical Reports Server (NTRS)

Bruno, Kristin J.; Welz, Linda L.; Barnes, G. Michael; Sherif, Josef

1993-01-01

A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.

A Memorandum Report: Physical Constants of MCE

DTIC Science & Technology

2016-08-01

published on 16 July 1945 by the Chemical Warfare Service (Edgewood Arsenal, MD) as T.D.M.R. 1094 (Control No. 5004- 1094 ). The report is being...MCE; T.D.M.R. 1094 ; Chemical Warfare Service: Edgewood Arsenal, MD, 1945; SECRET Report (ADB964103). The purpose of this report is to correct two...technical errors recently found in T.D.M.R. 1094 . The first error appears to be a transcription error for the vapor pressure value listed in Table 2

[Interpersonal competence in orthopedics and traumatology : Why technical and procedural skills alone are not sufficient].

PubMed

Seemann, R; Münzberg, M; Stange, R; Rüsseler, M; Egerth, M; Bouillon, B; Hoffmann, R; Mutschler, M

2016-10-01

Patient safety has increasingly gained significance as criterion which clinics and doctors will be measured against in terms of ethics and finances. The "human factor" moved into focus regarding the question of how to reduce treatment errors in clinical daily routine. Nevertheless, systematic mediation of interpersonal competences only plays a minor role in the catalogue of requirements for medical specialization and professional training. This is the case not only in orthopedics and traumatology, but in other medical fields as well. At the insistence of DGOU and in cooperation with Lufthansa Flight Training, a training model was initiated, comparable to training models used in aviation. In aviation, apart from the training of procedural and technical abilities, regular soft skills training has become standard in the training of all Lufthansa staff. Several studies confirm that by improving communication, interaction, and teamwork skills not only a reduction of intolerable incidents is observed, but also a positive economic effect. Interpersonal competences should be firmly anchored in orthopedics and traumatology and thus be implemented as third post in specialist training.

Human Error and the International Space Station: Challenges and Triumphs in Science Operations

NASA Technical Reports Server (NTRS)

Harris, Samantha S.; Simpson, Beau C.

2016-01-01

Any system with a human component is inherently risky. Studies in human factors and psychology have repeatedly shown that human operators will inevitably make errors, regardless of how well they are trained. Onboard the International Space Station (ISS) where crew time is arguably the most valuable resource, errors by the crew or ground operators can be costly to critical science objectives. Operations experts at the ISS Payload Operations Integration Center (POIC), located at NASA's Marshall Space Flight Center in Huntsville, Alabama, have learned that from payload concept development through execution, there are countless opportunities to introduce errors that can potentially result in costly losses of crew time and science. To effectively address this challenge, we must approach the design, testing, and operation processes with two specific goals in mind. First, a systematic approach to error and human centered design methodology should be implemented to minimize opportunities for user error. Second, we must assume that human errors will be made and enable rapid identification and recoverability when they occur. While a systematic approach and human centered development process can go a long way toward eliminating error, the complete exclusion of operator error is not a reasonable expectation. The ISS environment in particular poses challenging conditions, especially for flight controllers and astronauts. Operating a scientific laboratory 250 miles above the Earth is a complicated and dangerous task with high stakes and a steep learning curve. While human error is a reality that may never be fully eliminated, smart implementation of carefully chosen tools and techniques can go a long way toward minimizing risk and increasing the efficiency of NASA's space science operations.

Challenges and opportunities for structural DNA nanotechnology

PubMed Central

Pinheiro, Andre V.; Han, Dongran; Shih, William M.; Yan, Hao

2012-01-01

DNA molecules have been used to build a variety of nanoscale structures and devices over the past 30 years, and potential applications have begun to emerge. But the development of more advanced structures and applications will require a number of issues to be addressed, the most significant of which are the high cost of DNA and the high error rate of self-assembly. Here we examine the technical challenges in the field of structural DNA nanotechnology and outline some of the promising applications that could be developed if these hurdles can be overcome. In particular, we highlight the potential use of DNA nanostructures in molecular and cellular biophysics, as biomimetic systems, in energy transfer and photonics, and in diagnostics and therapeutics for human health. PMID:22056726

More explicit communication after classroom-based crew resource management training: results of a pragmatic trial.

PubMed

Verbeek-van Noord, Inge; de Bruijne, Martine C; Twisk, Jos W R; van Dyck, Cathy; Wagner, Cordula

2015-02-01

Aviation-based crew resource management trainings to optimize non-technical skills among professionals are often suggested for health care as a way to increase patient safety. Our aim was to evaluate the effect of a 2-day classroom-based crew resource management (CRM) training at emergency departments (EDs) on explicit professional oral communication (EPOC; non-technical skills). A pragmatic controlled before-after trial was conducted. Four EDs of general teaching hospitals were recruited (two intervention and two control departments). ED nurses and ED doctors were observed on their non-technical skills by means of a validated observation tool (EPOC). Our main outcome measure was the amount of EPOC observed per interaction in 30 minutes direct observations. Three outcome measures from EPOC were analysed: human interaction, anticipation on environment and an overall EPOC score. Linear and logistic mixed model analyses were performed. Models were corrected for the outcome measurement at baseline, days between training and observation, patient safety culture and error management culture at baseline. A statistically significant increase after the training was found on human interaction (β=0.27, 95% CI 0.08-0.49) and the overall EPOC score (β=0.25, 95% CI 0.06-0.43), but not for anticipation on environment (OR=1.19, 95% CI .45-3.15). This means that approximately 25% more explicit communication was shown after CRM training. We found an increase in the use of CRM skills after classroom-based crew resource management training. This study adds to the body of evidence that CRM trainings have the potential to increase patient safety by reducing communication flaws, which play an important role in health care-related adverse events. © 2014 John Wiley & Sons, Ltd.

Modeling human response errors in synthetic flight simulator domain

NASA Technical Reports Server (NTRS)

Ntuen, Celestine A.

1992-01-01

This paper presents a control theoretic approach to modeling human response errors (HRE) in the flight simulation domain. The human pilot is modeled as a supervisor of a highly automated system. The synthesis uses the theory of optimal control pilot modeling for integrating the pilot's observation error and the error due to the simulation model (experimental error). Methods for solving the HRE problem are suggested. Experimental verification of the models will be tested in a flight quality handling simulation.

Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

NASA Technical Reports Server (NTRS)

Wiegmann, Douglas A.; Rantanen, Esa; Crisp, Vicki K. (Technical Monitor)

2002-01-01

One of the main factors in all aviation accidents is human error. The NASA Aviation Safety Program (AvSP), therefore, has identified several human-factors safety technologies to address this issue. Some technologies directly address human error either by attempting to reduce the occurrence of errors or by mitigating the negative consequences of errors. However, new technologies and system changes may also introduce new error opportunities or even induce different types of errors. Consequently, a thorough understanding of the relationship between error classes and technology "fixes" is crucial for the evaluation of intervention strategies outlined in the AvSP, so that resources can be effectively directed to maximize the benefit to flight safety. The purpose of the present project, therefore, was to examine the repositories of human factors data to identify the possible relationship between different error class and technology intervention strategies. The first phase of the project, which is summarized here, involved the development of prototype data structures or matrices that map errors onto "fixes" (and vice versa), with the hope of facilitating the development of standards for evaluating safety products. Possible follow-on phases of this project are also discussed. These additional efforts include a thorough and detailed review of the literature to fill in the data matrix and the construction of a complete database and standards checklists.

Human Factors in Training - Space Flight Resource Management Training

NASA Technical Reports Server (NTRS)

Bryne, Vicky; Connell, Erin; Barshi, Immanuel; Arsintescu, L.

2009-01-01

Accidents and incidents show that high workload-induced stress and poor teamwork skills lead to performance decrements and errors. Research on teamwork shows that effective teams are able to adapt to stressful situations, and to reduce workload by using successful strategies for communication and decision making, and through dynamic redistribution of tasks among team members. Furthermore, superior teams are able to recognize signs and symptoms of workload-induced stress early, and to adapt their coordination and communication strategies to the high workload, or stress conditions. Mission Control Center (MCC) teams often face demanding situations in which they must operate as an effective team to solve problems with crew and vehicle during onorbit operations. To be successful as a team, flight controllers (FCers) must learn effective teamwork strategies. Such strategies are the focus of Space Flight Resource Management (SFRM) training. SFRM training in MOD has been structured to include some classroom presentations of basic concepts and case studies, with the assumption that skill development happens in mission simulation. Integrated mission simulations do provide excellent opportunities for FCers to practice teamwork, but also require extensive technical knowledge of vehicle systems, mission operations, and crew actions. Such technical knowledge requires lengthy training. When SFRM training is relegated to integrated simulations, FCers can only practice SFRM after they have already mastered the technical knowledge necessary for these simulations. Given the centrality of teamwork to the success of MCC, holding SFRM training till late in the flow is inefficient. But to be able to train SFRM earlier in the flow, the training cannot rely on extensive mission-specific technical knowledge. Hence, the need for a generic SFRM training framework that would allow FCers to develop basic teamwork skills which are mission relevant, but without the required mission knowledge. Work on SFRM training has been conducted in collaboration with the Expedition Vehicle Division at the Mission Operations Directorate (MOD) and with United Space Alliance (USA) which provides training to Flight Controllers. The space flight resource management training work is part of the Human Factors in Training Directed Research Project (DRP) of the Space Human Factors Engineering (SHFE) Project under the Space Human Factors and Habitability (SHFH) Element of the Human Research Program (HRP). Human factors researchers at the Ames Research Center have been investigating team work and distributed decision making processes to develop a generic SFRM training framework for flight controllers. The work proposed for FY10 continues to build on this strong collaboration with MOD and the USA Training Group as well as previous research in relevant domains such as aviation. In FY10, the work focuses on documenting and analyzing problem solving strategies and decision making processes used in MCC by experienced FCers.

A low-cost, computer-controlled robotic flower system for behavioral experiments.

PubMed

Kuusela, Erno; Lämsä, Juho

2016-04-01

Human observations during behavioral studies are expensive, time-consuming, and error prone. For this reason, automatization of experiments is highly desirable, as it reduces the risk of human errors and workload. The robotic system we developed is simple and cheap to build and handles feeding and data collection automatically. The system was built using mostly off-the-shelf components and has a novel feeding mechanism that uses servos to perform refill operations. We used the robotic system in two separate behavioral studies with bumblebees (Bombus terrestris): The system was used both for training of the bees and for the experimental data collection. The robotic system was reliable, with no flight in our studies failing due to a technical malfunction. The data recorded were easy to apply for further analysis. The software and the hardware design are open source. The development of cheap open-source prototyping platforms during the recent years has opened up many possibilities in designing of experiments. Automatization not only reduces workload, but also potentially allows experimental designs never done before, such as dynamic experiments, where the system responds to, for example, learning of the animal. We present a complete system with hardware and software, and it can be used as such in various experiments requiring feeders and collection of visitation data. Use of the system is not limited to any particular experimental setup or even species.

Technical note: estimating sex using cervical canine odontometrics: a test using a known sex sample.

PubMed

Hassett, Brenna

2011-11-01

The size of the permanent human canine tooth is one of the few sexually dimorphic features to be present in childhood and as such offers the opportunity to assist in the identification of sex in remains where no other appropriate criteria exist, such as in subadults. However, canine odontometrics are often associated with high levels of interobserver error and can be difficult to access if dentition is in situ. Additionally, appropriate points of measurement can be difficult to identify if the tooth is worn. Alternate measurements of the cervical canine diameters have been proposed as solutions to these issues, but the utility of these measurements in estimating sex has not been conclusively demonstrated. This study uses the buccolingual and mesiodistal cervical diameter of the canines from a known-sex sample from St. Bride's Church, London and a partially known-sex sample from the Old Church, Chelsea, London to classify individuals as male or female. A discriminant function classification using these diameters successfully identifies sex in 93.8% of the known-sex assemblage and 95% of the partially osteologically estimated sex assemblage. It is suggested that cervical canine diameters are highly repeatable measurements with low interobserver error, can be obtained on worn and in situ teeth, and provide as good or better guidance on estimating sex in human remains as standard maximal diameters. Copyright © 2011 Wiley-Liss, Inc.

[Safety Culture in Orthopaedic Surgery and Trauma Surgery - Where Are We Today?

PubMed

Münzberg, Matthias; Rüsseler, Miriam; Egerth, Martin; Doepfer, Anna Katharina; Mutschler, Manuel; Stange, Richard; Bouillon, Bertil; Kladny, Bernd; Hoffmann, Reinhard

2018-06-05

The development of a new safety culture in orthopaedics and trauma surgery needs to be based on the knowledge of the status quo. The objective of this research was therefore to perform a survey of orthopaedic and trauma surgeons to achieve a subjective assessment of the frequency and causes of "insecurities" or errors in daily practice. Based on current literature, an online questionnaire was created by a team of experts (26 questions total) and was sent via e-mail to all active members of a medical society (DGOU) in April 2015. This was followed by two reminder e-mails. The survey was completed in May 2015. The results were transmitted electronically, anonymously and voluntarily into a database and evaluated by univariate analyses. 799 active members took part in the survey. 65% of the interviewed people stated that they noticed mistakes in their own clinical work environment at least once a week. The main reasons for these mistakes were "time pressure", "lack of communication", "lack of staff" and "stress". Technical mistakes or lack of knowledge were not of primary importance. The survey indicated that errors in orthopaedics and trauma surgery are observed regularly. "Human factors" were regarded as a major cause. In order to develop a new safety culture in orthopaedics and trauma surgery, new approaches must focus on the human factor. Georg Thieme Verlag KG Stuttgart · New York.

Evaluation of complications of root canal treatment performed by undergraduate dental students.

PubMed

AlRahabi, Mothanna K

2017-12-01

This study evaluated the technical quality of root canal treatment (RCT) and detected iatrogenic errors in an undergraduate dental clinic at the College of Dentistry, Taibah University, Saudi Arabia. Dental records of 280 patients who received RCT between 2013 and 2016 undertaken by dental students were investigated by retrospective chart review. Root canal obturation was evaluated on the basis of the length of obturation being ≤2 mm from the radiographic apex, with uniform radiodensity and good adaptation to root canal walls. Inadequate root canal obturation included cases containing procedural errors such as furcal perforation, ledge, canal transportation, strip perforation, root perforation, instrument separation, voids in the obturation, or underfilling or overfilling of the obturation. In 193 (68.9%) teeth, RCT was adequate and without procedural errors. However, in 87 (31.1%) teeth, RCT was inadequate and contained procedural errors. The frequency of procedural errors in the entire sample was 31.1% as follows: underfilling, 49.9%; overfilling, 24.1%; voids, 12.6%; broken instruments, 9.2%; apical perforation, 2.3%; and root canal transportation, 2.3%. There were no significant differences (p > 0.05) in the type or frequency of procedural errors between the fourth- and fifth-year students. Lower molars (43.1%) and upper incisors (19.2%) exhibited the highest and lowest frequencies of procedural errors, respectively. The technical quality of RCT performed by undergraduate dental students was classified as 'adequate' in 68.9% of the cases. There is a need for improvement in the training of students at the preclinical and clinical levels.

Development and implementation of a human accuracy program in patient foodservice.

PubMed

Eden, S H; Wood, S M; Ptak, K M

1987-04-01

For many years, industry has utilized the concept of human error rates to monitor and minimize human errors in the production process. A consistent quality-controlled product increases consumer satisfaction and repeat purchase of product. Administrative dietitians have applied the concepts of using human error rates (the number of errors divided by the number of opportunities for error) at four hospitals, with a total bed capacity of 788, within a tertiary-care medical center. Human error rate was used to monitor and evaluate trayline employee performance and to evaluate layout and tasks of trayline stations, in addition to evaluating employees in patient service areas. Long-term employees initially opposed the error rate system with some hostility and resentment, while newer employees accepted the system. All employees now believe that the constant feedback given by supervisors enhances their self-esteem and productivity. Employee error rates are monitored daily and are used to counsel employees when necessary; they are also utilized during annual performance evaluation. Average daily error rates for a facility staffed by new employees decreased from 7% to an acceptable 3%. In a facility staffed by long-term employees, the error rate increased, reflecting improper error documentation. Patient satisfaction surveys reveal satisfaction, for tray accuracy increased from 88% to 92% in the facility staffed by long-term employees and has remained above the 90% standard in the facility staffed by new employees.

Comprehensive Anti-error Study on Power Grid Dispatching Based on Regional Regulation and Integration

NASA Astrophysics Data System (ADS)

Zhang, Yunju; Chen, Zhongyi; Guo, Ming; Lin, Shunsheng; Yan, Yinyang

2018-01-01

With the large capacity of the power system, the development trend of the large unit and the high voltage, the scheduling operation is becoming more frequent and complicated, and the probability of operation error increases. This paper aims at the problem of the lack of anti-error function, single scheduling function and low working efficiency for technical support system in regional regulation and integration, the integrated construction of the error prevention of the integrated architecture of the system of dispatching anti - error of dispatching anti - error of power network based on cloud computing has been proposed. Integrated system of error prevention of Energy Management System, EMS, and Operation Management System, OMS have been constructed either. The system architecture has good scalability and adaptability, which can improve the computational efficiency, reduce the cost of system operation and maintenance, enhance the ability of regional regulation and anti-error checking with broad development prospects.

77 FR 39543 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Order Approving a Proposed Rule...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-03

... the Authority of NASDAQ or NASDAQ Execution Services To Cancel Orders When a Technical or Systems...'') to cancel orders when a technical or systems issue occurs and to describe the operation of an error... causes NASDAQ or NES to cancel orders, if NASDAQ or NES determines that such action is necessary to...

Reflections on human error - Matters of life and death

NASA Technical Reports Server (NTRS)

Wiener, Earl L.

1989-01-01

The last two decades have witnessed a rapid growth in the introduction of automatic devices into aircraft cockpits, and eleswhere in human-machine systems. This was motivated in part by the assumption that when human functioning is replaced by machine functioning, human error is eliminated. Experience to date shows that this is far from true, and that automation does not replace humans, but changes their role in the system, as well as the types and severity of the errors they make. This altered role may lead to fewer, but more critical errors. Intervention strategies to prevent these errors, or ameliorate their consequences include basic human factors engineering of the interface, enhanced warning and alerting systems, and more intelligent interfaces that understand the strategic intent of the crew and can detect and trap inconsistent or erroneous input before it affects the system.

FMEA: a model for reducing medical errors.

PubMed

Chiozza, Maria Laura; Ponzetti, Clemente

2009-06-01

Patient safety is a management issue, in view of the fact that clinical risk management has become an important part of hospital management. Failure Mode and Effect Analysis (FMEA) is a proactive technique for error detection and reduction, firstly introduced within the aerospace industry in the 1960s. Early applications in the health care industry dating back to the 1990s included critical systems in the development and manufacture of drugs and in the prevention of medication errors in hospitals. In 2008, the Technical Committee of the International Organization for Standardization (ISO), licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. Here we describe the main steps of the FMEA process and review data available on the application of this technique to laboratory medicine. A significant reduction of the risk priority number (RPN) was obtained when applying FMEA to blood cross-matching, to clinical chemistry analytes, as well as to point-of-care testing (POCT).

Determining the Numeracy and Algebra Errors of Students in a Two-Year Vocational School

ERIC Educational Resources Information Center

Akyüz, Gözde

2015-01-01

The goal of this study was to determine the mathematics achievement level in basic numeracy and algebra concepts of students in a two-year program in a technical vocational school of higher education and determine the errors that they make in these topics. The researcher developed a diagnostic mathematics achievement test related to numeracy and…

Comparison of Efficiency of Jackknife and Variance Component Estimators of Standard Errors. Program Statistics Research. Technical Report.

ERIC Educational Resources Information Center

Longford, Nicholas T.

Large scale surveys usually employ a complex sampling design and as a consequence, no standard methods for estimation of the standard errors associated with the estimates of population means are available. Resampling methods, such as jackknife or bootstrap, are often used, with reference to their properties of robustness and reduction of bias. A…

Technical Note: Error metrics for estimating the accuracy of needle/instrument placement during transperineal magnetic resonance/ultrasound-guided prostate interventions.

PubMed

Bonmati, Ester; Hu, Yipeng; Villarini, Barbara; Rodell, Rachael; Martin, Paul; Han, Lianghao; Donaldson, Ian; Ahmed, Hashim U; Moore, Caroline M; Emberton, Mark; Barratt, Dean C

2018-04-01

Image-guided systems that fuse magnetic resonance imaging (MRI) with three-dimensional (3D) ultrasound (US) images for performing targeted prostate needle biopsy and minimally invasive treatments for prostate cancer are of increasing clinical interest. To date, a wide range of different accuracy estimation procedures and error metrics have been reported, which makes comparing the performance of different systems difficult. A set of nine measures are presented to assess the accuracy of MRI-US image registration, needle positioning, needle guidance, and overall system error, with the aim of providing a methodology for estimating the accuracy of instrument placement using a MR/US-guided transperineal approach. Using the SmartTarget fusion system, an MRI-US image alignment error was determined to be 2.0 ± 1.0 mm (mean ± SD), and an overall system instrument targeting error of 3.0 ± 1.2 mm. Three needle deployments for each target phantom lesion was found to result in a 100% lesion hit rate and a median predicted cancer core length of 5.2 mm. The application of a comprehensive, unbiased validation assessment for MR/US guided systems can provide useful information on system performance for quality assurance and system comparison. Furthermore, such an analysis can be helpful in identifying relationships between these errors, providing insight into the technical behavior of these systems. © 2018 American Association of Physicists in Medicine.

Technical errors in planar bone scanning.

PubMed

Naddaf, Sleiman Y; Collier, B David; Elgazzar, Abdelhamid H; Khalil, Magdy M

2004-09-01

Optimal technique for planar bone scanning improves image quality, which in turn improves diagnostic efficacy. Because planar bone scanning is one of the most frequently performed nuclear medicine examinations, maintaining high standards for this examination is a daily concern for most nuclear medicine departments. Although some problems such as patient motion are frequently encountered, the degraded images produced by many other deviations from optimal technique are rarely seen in clinical practice and therefore may be difficult to recognize. The objectives of this article are to list optimal techniques for 3-phase and whole-body bone scanning, to describe and illustrate a selection of deviations from these optimal techniques for planar bone scanning, and to explain how to minimize or avoid such technical errors.

Diagnosis of the Computer-Controlled Milling Machine, Definition of the Working Errors and Input Corrections on the Basis of Mathematical Model

NASA Astrophysics Data System (ADS)

Starikov, A. I.; Nekrasov, R. Yu; Teploukhov, O. J.; Soloviev, I. V.; Narikov, K. A.

2016-10-01

Manufactures, machinery and equipment improve of constructively as science advances and technology, and requirements are improving of quality and longevity. That is, the requirements for surface quality and precision manufacturing, oil and gas equipment parts are constantly increasing. Production of oil and gas engineering products on modern machine tools with computer numerical control - is a complex synthesis of technical and electrical equipment parts, as well as the processing procedure. Technical machine part wears during operation and in the electrical part are accumulated mathematical errors. Thus, the above-mentioned disadvantages of any of the following parts of metalworking equipment affect the manufacturing process of products in general, and as a result lead to the flaw.

Developing Human Resources for the Technical Workforce: A Comparative Study of Korea and Thailand

ERIC Educational Resources Information Center

Hawley, Joshua D.; Paek, Jeeyon

2005-01-01

Asian countries face significant and growing shortages of technically skilled workers. Vocational-technical systems are key components of national human resource development. Using labor market data from Thailand and Korea, this paper analyzes the economic payoff for individual investment in vocational-technical education, and subsequent…

Human factors process failure modes and effects analysis (HF PFMEA) software tool

NASA Technical Reports Server (NTRS)

Chandler, Faith T. (Inventor); Relvini, Kristine M. (Inventor); Shedd, Nathaneal P. (Inventor); Valentino, William D. (Inventor); Philippart, Monica F. (Inventor); Bessette, Colette I. (Inventor)

2011-01-01

Methods, computer-readable media, and systems for automatically performing Human Factors Process Failure Modes and Effects Analysis for a process are provided. At least one task involved in a process is identified, where the task includes at least one human activity. The human activity is described using at least one verb. A human error potentially resulting from the human activity is automatically identified, the human error is related to the verb used in describing the task. A likelihood of occurrence, detection, and correction of the human error is identified. The severity of the effect of the human error is identified. The likelihood of occurrence, and the severity of the risk of potential harm is identified. The risk of potential harm is compared with a risk threshold to identify the appropriateness of corrective measures.

Air Force Academy Homepage

Science.gov Websites

Chaplain Corps Cadet Chapel Community Center Chapel Institutional Review Board Not Human Subjects Research Requirements 7 Not Human Subjects Research Form 8 Researcher Instructions - Activities Submitted to DoD IRB 9 Review 18 Not Human Subjects Errors 19 Exempt Research Most Frequent Errors 20 Most Frequent Errors for

Development of an FAA-EUROCONTROL technique for the analysis of human error in ATM : final report.

DOT National Transportation Integrated Search

2002-07-01

Human error has been identified as a dominant risk factor in safety-oriented industries such as air traffic control (ATC). However, little is known about the factors leading to human errors in current air traffic management (ATM) systems. The first s...

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)

Pyrometer with tracking balancing

NASA Astrophysics Data System (ADS)

Ponomarev, D. B.; Zakharenko, V. A.; Shkaev, A. G.

2018-04-01

Currently, one of the main metrological noncontact temperature measurement challenges is the emissivity uncertainty. This paper describes a pyrometer with emissivity effect diminishing through the use of a measuring scheme with tracking balancing in which the radiation receiver is a null-indicator. In this paper the results of the prototype pyrometer absolute error study in surfaces temperature measurement of aluminum and nickel samples are presented. There is absolute error calculated values comparison considering the emissivity table values with errors on the results of experimental measurements by the proposed method. The practical implementation of the proposed technical solution has allowed two times to reduce the error due to the emissivity uncertainty.

Human Factors Throughout the Life Cycle: Lessons Learned from the Shuttle Program. [Human Factors in Ground Processing

NASA Technical Reports Server (NTRS)

Kanki, Barbara G.

2011-01-01

With the ending of the Space Shuttle Program, it is critical that we not forget the Human Factors lessons we have learned over the years. At every phase of the life cycle, from manufacturing, processing and integrating vehicle and payload, to launch, flight operations, mission control and landing, hundreds of teams have worked together to achieve mission success in one of the most complex, high-risk socio-technical enterprises ever designed. Just as there was great diversity in the types of operations performed at every stage, there was a myriad of human factors that could further complicate these human systems. A single mishap or close call could point to issues at the individual level (perceptual or workload limitations, training, fatigue, human error susceptibilities), the task level (design of tools, procedures and aspects of the workplace), as well as the organizational level (appropriate resources, safety policies, information access and communication channels). While we have often had to learn through human mistakes and technological failures, we have also begun to understand how to design human systems in which individuals can excel, where tasks and procedures are not only safe but efficient, and how organizations can foster a proactive approach to managing risk and supporting human enterprises. Panelists will talk about their experiences as they relate human factors to a particular phase of the shuttle life cycle. They will conclude with a framework for tying together human factors lessons-learned into system-level risk management strategies.

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.

Psychomotor performance measured in a virtual environment correlates with technical skills in the operating room.

PubMed

Kundhal, Pavi S; Grantcharov, Teodor P

2009-03-01

This study was conducted to validate the role of virtual reality computer simulation as an objective method for assessing laparoscopic technical skills. The authors aimed to investigate whether performance in the operating room, assessed using a modified Objective Structured Assessment of Technical Skill (OSATS), correlated with the performance parameters registered by a virtual reality laparoscopic trainer (LapSim). The study enrolled 10 surgical residents (3 females) with a median of 5.5 years (range, 2-6 years) since graduation who had similar limited experience in laparoscopic surgery (median, 5; range, 1-16 laparoscopic cholecystectomies). All the participants performed three repetitions of seven basic skills tasks on the LapSim laparoscopic trainer and one laparoscopic cholecystectomy in the operating room. The operating room procedure was video recorded and blindly assessed by two independent observers using a modified OSATS rating scale. Assessment in the operating room was based on three parameters: time used, error score, and economy of motion score. During the tasks on the LapSim, time, error (tissue damage and millimeters of tissue damage [tasks 2-6], error score [incomplete target areas, badly placed clips, and dropped clips [task 7]), and economy of movement parameters (path length and angular path) were registered. The correlation between time, economy, and error parameters during the simulated tasks and the operating room procedure was statistically assessed using Spearman's test. Significant correlations were demonstrated between the time used to complete the operating room procedure and time used for task 7 (r (s) = 0.74; p = 0.015). The error score demonstrated during the laparoscopic cholecystectomy correlated well with the tissue damage in three of the seven tasks (p < 0.05), the millimeters of tissue damage during two of the tasks, and the error score in task 7 (r (s) = 0.67; p = 0.034). Furthermore, statistically significant correlations were observed between the economy of motion score from the operative procedure and LapSim's economy parameters (path length and angular path in six of the tasks) (p < 0.05). The current study demonstrated significant correlations between operative performance in the operating room (assessed using a well-validated rating scale) and psychomotor performance in virtual environment assessed by a computer simulator. This provides strong evidence for the validity of the simulator system as an objective tool for assessing laparoscopic skills. Virtual reality simulation can be used in practice to assess technical skills relevant for minimally invasive surgery.

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.

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

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

Lon N. Haney; David I. Gertman

2003-04-01

Beginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human errormore » analysis, and develop an approach addressing these needs. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.« less

Risk analysis by FMEA as an element of analytical validation.

PubMed

van Leeuwen, J F; Nauta, M J; de Kaste, D; Odekerken-Rombouts, Y M C F; Oldenhof, M T; Vredenbregt, M J; Barends, D M

2009-12-05

We subjected a Near-Infrared (NIR) analytical procedure used for screening drugs on authenticity to a Failure Mode and Effects Analysis (FMEA), including technical risks as well as risks related to human failure. An FMEA team broke down the NIR analytical method into process steps and identified possible failure modes for each step. Each failure mode was ranked on estimated frequency of occurrence (O), probability that the failure would remain undetected later in the process (D) and severity (S), each on a scale of 1-10. Human errors turned out to be the most common cause of failure modes. Failure risks were calculated by Risk Priority Numbers (RPNs)=O x D x S. Failure modes with the highest RPN scores were subjected to corrective actions and the FMEA was repeated, showing reductions in RPN scores and resulting in improvement indices up to 5.0. We recommend risk analysis as an addition to the usual analytical validation, as the FMEA enabled us to detect previously unidentified risks.

Annotated Bibliography of the Air Force Human Resources Laboratory Technical Reports - 1979.

DTIC Science & Technology

1981-05-01

Force Human Resources Laboratory, March 1980. (Covers all AFHRL projects.) NTIS. This document provides the academic and industrial R&D community with...D-AI02 04𔃾 AIR FORCE HUMAN RESOURCES LAB BROOKS AF TX F/G 5/2 ANNOTATED BIBLIOGRAPHY OF THE AIR FORCE HUMAN RESOURCES LABORAT--ETC(U) MAY 81 E M...OF THE AIR FORCE HUMAN RESOURCES LABORATORY TECHNICAL REPORTS - 1979U M By M Esther M. Barlow A N TECHNICAL SERVICES DIVISION Brooks Air Force Base

Analysis of measured data of human body based on error correcting frequency

NASA Astrophysics Data System (ADS)

Jin, Aiyan; Peipei, Gao; Shang, Xiaomei

2014-04-01

Anthropometry is to measure all parts of human body surface, and the measured data is the basis of analysis and study of the human body, establishment and modification of garment size and formulation and implementation of online clothing store. In this paper, several groups of the measured data are gained, and analysis of data error is gotten by analyzing the error frequency and using analysis of variance method in mathematical statistics method. Determination of the measured data accuracy and the difficulty of measured parts of human body, further studies of the causes of data errors, and summarization of the key points to minimize errors possibly are also mentioned in the paper. This paper analyses the measured data based on error frequency, and in a way , it provides certain reference elements to promote the garment industry development.

Navigation Operational Concept,

DTIC Science & Technology

1991-08-01

Area Control Facility AFSS Automated Flight Service Station AGL Above Ground Level ALSF-2 Approach Light System with Sequence Flasher Model 2 ATC Air...equipment contributes less than 0.30 NM error at the missed approach point. This total system use accuracy allows for flight technical error of up to...means for transition from instrument to visual flight . This function is provided by a series of standard lighting systems : the Approach Lighting

Publisher Correction: The global distribution of tetrapods reveals a need for targeted reptile conservation.

PubMed

Roll, Uri; Feldman, Anat; Novosolov, Maria; Allison, Allen; Bauer, Aaron M; Bernard, Rodolphe; Böhm, Monika; Castro-Herrera, Fernando; Chirio, Laurent; Collen, Ben; Colli, Guarino R; Dabool, Lital; Das, Indraneil; Doan, Tiffany M; Grismer, Lee L; Hoogmoed, Marinus; Itescu, Yuval; Kraus, Fred; LeBreton, Matthew; Lewin, Amir; Martins, Marcio; Maza, Erez; Meirte, Danny; Nagy, Zoltán T; de C Nogueira, Cristiano; Pauwels, Olivier S G; Pincheira-Donoso, Daniel; Powney, Gary D; Sindaco, Roberto; Tallowin, Oliver J S; Torres-Carvajal, Omar; Trape, Jean-François; Vidan, Enav; Uetz, Peter; Wagner, Philipp; Wang, Yuezhao; Orme, C David L; Grenyer, Richard; Meiri, Shai

2017-11-01

In this Article originally published, owing to a technical error, the author 'Laurent Chirio' was mistakenly designated as a corresponding author in the HTML version, the PDF was correct. This error has now been corrected in the HTML version. Further, in Supplementary Table 3, the authors misspelt the surname of 'Danny Meirte'; this file has now been replaced.

10 CFR 26.137 - Quality assurance and quality control.

Code of Federal Regulations, 2013 CFR

2013-01-01

... validation of analytical procedures. Quality assurance procedures must be designed, implemented, and reviewed... resolving any technical, methodological, or administrative errors in the licensee testing facility's testing...

10 CFR 26.137 - Quality assurance and quality control.

Code of Federal Regulations, 2010 CFR

2010-01-01

... validation of analytical procedures. Quality assurance procedures must be designed, implemented, and reviewed... resolving any technical, methodological, or administrative errors in the licensee testing facility's testing...

10 CFR 26.137 - Quality assurance and quality control.

Code of Federal Regulations, 2011 CFR

2011-01-01

... validation of analytical procedures. Quality assurance procedures must be designed, implemented, and reviewed... resolving any technical, methodological, or administrative errors in the licensee testing facility's testing...

10 CFR 26.137 - Quality assurance and quality control.

Code of Federal Regulations, 2012 CFR

2012-01-01

... validation of analytical procedures. Quality assurance procedures must be designed, implemented, and reviewed... resolving any technical, methodological, or administrative errors in the licensee testing facility's testing...

10 CFR 26.137 - Quality assurance and quality control.

Code of Federal Regulations, 2014 CFR

2014-01-01

... validation of analytical procedures. Quality assurance procedures must be designed, implemented, and reviewed... resolving any technical, methodological, or administrative errors in the licensee testing facility's testing...

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.

Using APEX to Model Anticipated Human Error: Analysis of a GPS Navigational Aid

NASA Technical Reports Server (NTRS)

VanSelst, Mark; Freed, Michael; Shefto, Michael (Technical Monitor)

1997-01-01

The interface development process can be dramatically improved by predicting design facilitated human error at an early stage in the design process. The approach we advocate is to SIMULATE the behavior of a human agent carrying out tasks with a well-specified user interface, ANALYZE the simulation for instances of human error, and then REFINE the interface or protocol to minimize predicted error. This approach, incorporated into the APEX modeling architecture, differs from past approaches to human simulation in Its emphasis on error rather than e.g. learning rate or speed of response. The APEX model consists of two major components: (1) a powerful action selection component capable of simulating behavior in complex, multiple-task environments; and (2) a resource architecture which constrains cognitive, perceptual, and motor capabilities to within empirically demonstrated limits. The model mimics human errors arising from interactions between limited human resources and elements of the computer interface whose design falls to anticipate those limits. We analyze the design of a hand-held Global Positioning System (GPS) device used for radical and navigational decisions in small yacht recalls. The analysis demonstrates how human system modeling can be an effective design aid, helping to accelerate the process of refining a product (or procedure).

Proceedings of the Annual National Clinic on Technical Education (12th, Spokane, Washington, March 26-28, 1975). Human Resource Development: Technical Education's Challenge.

ERIC Educational Resources Information Center

Rutledge, Gene; And Others

This report includes the presentations of the speakers appearing before the National Clinic on Technical Education. Topics cover human resource development; the impact of technical education on economic development (in Mississippi); economics of allied health education; manpower implications of environmental protection; manpower needs for…

Human Resource Development: Technical Education's Challenge. Proceedings of the Annual National Clinic on Technical Education (12th, Spokane, Washington, March 26-28, 1975).

ERIC Educational Resources Information Center

Washington State Community Coll. District 17, Spokane.

Speeches and discussions are transcribed in this report, which also includes a listing of the American Technical Education Association (ATEA) committee members, exhibitors, officers, and directory of speakers. Speeches covered "Human Resource Development" by Gene Rutledge; "The Impact of Technical Education on Economic…

Accuracy of Jump-Mat Systems for Measuring Jump Height.

PubMed

Pueo, Basilio; Lipinska, Patrycja; Jiménez-Olmedo, José M; Zmijewski, Piotr; Hopkins, Will G

2017-08-01

Vertical-jump tests are commonly used to evaluate lower-limb power of athletes and nonathletes. Several types of equipment are available for this purpose. To compare the error of measurement of 2 jump-mat systems (Chronojump-Boscosystem and Globus Ergo Tester) with that of a motion-capture system as a criterion and to determine the modifying effect of foot length on jump height. Thirty-one young adult men alternated 4 countermovement jumps with 4 squat jumps. Mean jump height and standard deviations representing technical error of measurement arising from each device and variability arising from the subjects themselves were estimated with a novel mixed model and evaluated via standardization and magnitude-based inference. The jump-mat systems produced nearly identical measures of jump height (differences in means and in technical errors of measurement ≤1 mm). Countermovement and squat-jump height were both 13.6 cm higher with motion capture (90% confidence limits ±0.3 cm), but this very large difference was reduced to small unclear differences when adjusted to a foot length of zero. Variability in countermovement and squat-jump height arising from the subjects was small (1.1 and 1.5 cm, respectively, 90% confidence limits ±0.3 cm); technical error of motion capture was similar in magnitude (1.7 and 1.6 cm, ±0.3 and ±0.4 cm), and that of the jump mats was similar or smaller (1.2 and 0.3 cm, ±0.5 and ±0.9 cm). The jump-mat systems provide trustworthy measurements for monitoring changes in jump height. Foot length can explain the substantially higher jump height observed with motion capture.

Advanced Outage and Control Center: Strategies for Nuclear Plant Outage Work Status Capabilities

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

Gregory Weatherby

The research effort is a part of the Light Water Reactor Sustainability (LWRS) Program. LWRS is a research and development program sponsored by the Department of Energy, performed in close collaboration with industry to provide the technical foundations for licensing and managing the long-term, safe and economical operation of current nuclear power plants. The LWRS Program serves to help the US nuclear industry adopt new technologies and engineering solutions that facilitate the continued safe operation of the plants and extension of the current operating licenses. The Outage Control Center (OCC) Pilot Project was directed at carrying out the applied researchmore » for development and pilot of technology designed to enhance safe outage and maintenance operations, improve human performance and reliability, increase overall operational efficiency, and improve plant status control. Plant outage management is a high priority concern for the nuclear industry from cost and safety perspectives. Unfortunately, many of the underlying technologies supporting outage control are the same as those used in the 1980’s. They depend heavily upon large teams of staff, multiple work and coordination locations, and manual administrative actions that require large amounts of paper. Previous work in human reliability analysis suggests that many repetitive tasks, including paper work tasks, may have a failure rate of 1.0E-3 or higher (Gertman, 1996). With between 10,000 and 45,000 subtasks being performed during an outage (Gomes, 1996), the opportunity for human error of some consequence is a realistic concern. Although a number of factors exist that can make these errors recoverable, reducing and effectively coordinating the sheer number of tasks to be performed, particularly those that are error prone, has the potential to enhance outage efficiency and safety. Additionally, outage management requires precise coordination of work groups that do not always share similar objectives. Outage managers are concerned with schedule and cost, union workers are concerned with performing work that is commensurate with their trade, and support functions (safety, quality assurance, and radiological controls, etc.) are concerned with performing the work within the plants controls and procedures. Approaches to outage management should be designed to increase the active participation of work groups and managers in making decisions that closed the gap between competing objectives and the potential for error and process inefficiency.« less

Exploring human error in military aviation flight safety events using post-incident classification systems.

PubMed

Hooper, Brionny J; O'Hare, David P A

2013-08-01

Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations. This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.

Intensive Care Unit

MedlinePlus

... the OSHA Directorate of Technical Support and Emergency Management at (202) 693-2300 for assistance accessing PDF materials. * These files are provided for downloading. ... Scope | Glossary | References | Site Map | Credits [an error occurred ...

The application of SHERPA (Systematic Human Error Reduction and Prediction Approach) in the development of compensatory cognitive rehabilitation strategies for stroke patients with left and right brain damage.

PubMed

Hughes, Charmayne M L; Baber, Chris; Bienkiewicz, Marta; Worthington, Andrew; Hazell, Alexa; Hermsdörfer, Joachim

2015-01-01

Approximately 33% of stroke patients have difficulty performing activities of daily living, often committing errors during the planning and execution of such activities. The objective of this study was to evaluate the ability of the human error identification (HEI) technique SHERPA (Systematic Human Error Reduction and Prediction Approach) to predict errors during the performance of daily activities in stroke patients with left and right hemisphere lesions. Using SHERPA we successfully predicted 36 of the 38 observed errors, with analysis indicating that the proportion of predicted and observed errors was similar for all sub-tasks and severity levels. HEI results were used to develop compensatory cognitive strategies that clinicians could employ to reduce or prevent errors from occurring. This study provides evidence for the reliability and validity of SHERPA in the design of cognitive rehabilitation strategies in stroke populations.

An Analysis of U.S. Army Fratricide Incidents during the Global War on Terror (11 September 2001 to 31 March 2008)

DTIC Science & Technology

2010-03-15

Swiss cheese model of human error causation. ................................................................... 3  2. Results for the classification of...based on Reason’s “ Swiss cheese ” model of human error (1990). Figure 1 describes how an accident is likely to occur when all of the errors, or “holes...align. A detailed description of HFACS can be found in Wiegmann and Shappell (2003). Figure 1. The Swiss cheese model of human error

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

PubMed

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

2017-02-01

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

Single plane angiography: Current applications and limitations

NASA Technical Reports Server (NTRS)

Falsetti, H. L.; Carroll, R. J.

1975-01-01

Technical errors in measurement of one plane cineangiography are identified. Examples of angiographic estimates of left ventricular geometry are given. These estimates of contractility are useful in evaluating myocardial performance.

Addressing Common Student Technical Errors in Field Data Collection: An Analysis of a Citizen-Science Monitoring Project.

PubMed

Philippoff, Joanna; Baumgartner, Erin

2016-03-01

The scientific value of citizen-science programs is limited when the data gathered are inconsistent, erroneous, or otherwise unusable. Long-term monitoring studies, such as Our Project In Hawai'i's Intertidal (OPIHI), have clear and consistent procedures and are thus a good model for evaluating the quality of participant data. The purpose of this study was to examine the kinds of errors made by student researchers during OPIHI data collection and factors that increase or decrease the likelihood of these errors. Twenty-four different types of errors were grouped into four broad error categories: missing data, sloppiness, methodological errors, and misidentification errors. "Sloppiness" was the most prevalent error type. Error rates decreased with field trip experience and student age. We suggest strategies to reduce data collection errors applicable to many types of citizen-science projects including emphasizing neat data collection, explicitly addressing and discussing the problems of falsifying data, emphasizing the importance of using standard scientific vocabulary, and giving participants multiple opportunities to practice to build their data collection techniques and skills.

Trauma Non-Technical Training (TNT-2): the development, piloting and multilevel assessment of a simulation-based, interprofessional curriculum for team-based trauma resuscitation.

PubMed

Doumouras, Aristithes G; Keshet, Itay; Nathens, Avery B; Ahmed, Najma; Hicks, Christopher M

2014-10-01

Medical error is common during trauma resuscitations. Most errors are nontechnical, stemming from ineffective team leadership, nonstandardized communication among team members, lack of global situational awareness, poor use of resources and inappropriate triage and prioritization. We developed an interprofessional, simulation-based trauma team training curriculum for Canadian surgical trainees. Here we discuss its piloting and evaluation.

Comparison of the efficacy and technical accuracy of different rectangular collimators for intraoral radiography.

PubMed

Zhang, Wenjian; Abramovitch, Kenneth; Thames, Walter; Leon, Inga-Lill K; Colosi, Dan C; Goren, Arthur D

2009-07-01

The objective of this study was to compare the operating efficiency and technical accuracy of 3 different rectangular collimators. A full-mouth intraoral radiographic series excluding central incisor views were taken on training manikins by 2 groups of undergraduate dental and dental hygiene students. Three types of rectangular collimator were used: Type I ("free-hand"), Type II (mechanical interlocking), and Type III (magnetic collimator). Eighteen students exposed one side of the manikin with a Type I collimator and the other side with a Type II. Another 15 students exposed the manikin with Type I and Type III respectively. Type I is currently used for teaching and patient care at our institution and was considered as the control to which both Types II and III were compared. The time necessary to perform the procedure, subjective user friendliness, and the number of technique errors (placement, projection, and cone cut errors) were assessed. The Student t test or signed rank test was used to determine statistical difference (P

Human errors and measurement uncertainty

NASA Astrophysics Data System (ADS)

Kuselman, Ilya; Pennecchi, Francesca

2015-04-01

Evaluating the residual risk of human errors in a measurement and testing laboratory, remaining after the error reduction by the laboratory quality system, and quantifying the consequences of this risk for the quality of the measurement/test results are discussed based on expert judgments and Monte Carlo simulations. A procedure for evaluation of the contribution of the residual risk to the measurement uncertainty budget is proposed. Examples are provided using earlier published sets of expert judgments on human errors in pH measurement of groundwater, elemental analysis of geological samples by inductively coupled plasma mass spectrometry, and multi-residue analysis of pesticides in fruits and vegetables. The human error contribution to the measurement uncertainty budget in the examples was not negligible, yet also not dominant. This was assessed as a good risk management result.

Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

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

Callan, J.R.; Kelly, R.T.; Quinn, M.L.

1995-05-01

Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices usedmore » in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error.« less

Human error analysis of commercial aviation accidents using the human factors analysis and classification system (HFACS)

DOT National Transportation Integrated Search

2001-02-01

The Human Factors Analysis and Classification System (HFACS) is a general human error framework : originally developed and tested within the U.S. military as a tool for investigating and analyzing the human : causes of aviation accidents. Based upon ...

Evaluation and analysis of the orbital maneuvering vehicle video system

NASA Technical Reports Server (NTRS)

Moorhead, Robert J., II

1989-01-01

The work accomplished in the summer of 1989 in association with the NASA/ASEE Summer Faculty Research Fellowship Program at Marshall Space Flight Center is summarized. The task involved study of the Orbital Maneuvering Vehicle (OMV) Video Compression Scheme. This included such activities as reviewing the expected scenes to be compressed by the flight vehicle, learning the error characteristics of the communication channel, monitoring the CLASS tests, and assisting in development of test procedures and interface hardware for the bit error rate lab being developed at MSFC to test the VCU/VRU. Numerous comments and suggestions were made during the course of the fellowship period regarding the design and testing of the OMV Video System. Unfortunately from a technical point of view, the program appears at this point in time to be trouble from an expense prospective and is in fact in danger of being scaled back, if not cancelled altogether. This makes technical improvements prohibitive and cost-reduction measures necessary. Fortunately some cost-reduction possibilities and some significant technical improvements that should cost very little were identified.

Theoretical Aspects of the Patterns Recognition Statistical Theory Used for Developing the Diagnosis Algorithms for Complicated Technical Systems

NASA Astrophysics Data System (ADS)

Obozov, A. A.; Serpik, I. N.; Mihalchenko, G. S.; Fedyaeva, G. A.

2017-01-01

In the article, the problem of application of the pattern recognition (a relatively young area of engineering cybernetics) for analysis of complicated technical systems is examined. It is shown that the application of a statistical approach for hard distinguishable situations could be the most effective. The different recognition algorithms are based on Bayes approach, which estimates posteriori probabilities of a certain event and an assumed error. Application of the statistical approach to pattern recognition is possible for solving the problem of technical diagnosis complicated systems and particularly big powered marine diesel engines.

Safe patient care - safety culture and risk management in otorhinolaryngology.

PubMed

St Pierre, Michael

2013-12-13

Safety culture is positioned at the heart of an organization's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organization's maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organization's safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality. Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate stimulation based team trainings into their curriculum.

[Safe patient care: safety culture and risk management in otorhinolaryngology].

PubMed

St Pierre, M

2013-04-01

Safety culture is positioned at the heart of an organisation's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organizations maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organisation's "safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality.Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate simulation based team trainings into their curriculum. © Georg Thieme Verlag KG Stuttgart · New York.

Using media to teach how not to do psychotherapy.

PubMed

Gabbard, Glen; Horowitz, Mardi

2010-01-01

This article describes how using media depictions of psychotherapy may help in teaching psychiatric residents. Using the HBO series In Treatment as a model, the authors suggest how boundary transgressions and technical errors may inform residents about optimal psychotherapeutic approaches. The psychotherapy vignettes depicted in In Treatment show how errors in judgment may grow out of therapists' good intentions. These errors can be understood and used constructively for teaching. With the growing interest in depicting psychotherapy on popular TV series, the use of these sessions avoids confidentiality problems and may be a useful adjunct for teaching psychotherapy.

A transmission security framework for email-based telemedicine.

PubMed

Caffery, Liam J; Smith, Anthony C

2010-01-01

Encryption is used to convert an email message to an unreadable format thereby securing patient privacy during the transmission of the message across the Internet. Two available means of encryption are: public key infrastructure (PKI) used in conjunction with ordinary email and secure hypertext transfer protocol (HTTPS) used by secure web-mail applications. Both of these approaches have advantages and disadvantages in terms of viability, cost, usability and compliance. The aim of this study was develop an instrument to identify the most appropriate means of encrypting email communication for telemedicine. A multi-method approach was used to construct the instrument. Technical assessment and existing bodies of knowledge regarding the utility of PKI were analyzed, along with survey results from users of Queensland Health's Child and Youth Mental Health Service secure web-mail service. The resultant decision support model identified that the following conditions affect the choice of encryption technology: correspondent's risk perception, correspondent's identification to the security afforded by encryption, email-client used by correspondents, the tolerance to human error and the availability of technical resources. A decision support model is presented as a flow chart to identify the most appropriate encryption for a specific email-based telemedicine service.

Pilot training: What can surgeons learn from it?

PubMed

Sommer, Kai-Jörg

2014-03-01

To provide healthcare professionals with an insight into training in aviation and its possible transfer into surgery. From research online and into company archives, relevant publications and information were identified. Current airline pilot training consists of two categories, basic training and type-rating. Training methods comprise classroom instruction, computer-based training and practical training, in either the aircraft or a flight-training device, which ranges from a fixed-base flight-training device to a full flight simulator. Pilot training not only includes technical and procedural instruction, but also training in non-technical skills like crisis management, decision-making, leadership and communication. Training syllabuses, training devices and instructors are internationally standardized and these standards are legally binding. Re-qualification and recurrent training are mandatory at all stages of a pilot's and instructor's career. Surgeons and pilots have much in common, i.e., they work in a 'real-time' three-dimensional environment under high physiological and psychological stress, operating expensive equipment, and the ultimate cost for error is measured in human lives. However, their training differs considerably. Transferring these well-tried aviation methods into healthcare will make surgical training more efficient, more effective and ultimately safer.

Honeywell Technical Order Transfer Tests.

DTIC Science & Technology

1987-06-12

of simple corrections, a reasonable reproduction of the original could be generated. The quality was not good enough for a production environment. Lack of automated quality control (AQC) tools could account for the errors.

[Medical expert systems and clinical needs].

PubMed

Buscher, H P

1991-10-18

The rapid expansion of computer-based systems for problem solving or decision making in medicine, the so-called medical expert systems, emphasize the need for reappraisal of their indication and value. Where specialist knowledge is required, in particular where medical decisions are susceptible to error these systems will probably serve as a valuable support. In the near future computer-based systems should be able to aid the interpretation of findings of technical investigations and the control of treatment, especially where rapid reactions are necessary despite the need of complex analysis of investigated parameters. In the distant future complete support of diagnostic procedures from the history to final diagnosis is possible. It promises to be particularly attractive for the diagnosis of seldom diseases, for difficult differential diagnoses, and in the decision making in the case of expensive, risky or new diagnostic or therapeutic methods. The physician needs to be aware of certain dangers, ranging from misleading information up to abuse. Patient information depends often on subjective reports and error-prone observations. Although basing on problematic knowledge computer-born decisions may have an imperative effect on medical decision making. Also it must be born in mind that medical decisions should always combine the rational with a consideration of human motives.

Human research ethics committees in technical universities.

PubMed

Koepsell, David; Brinkman, Willem-Paul; Pont, Sylvia

2014-07-01

Human research ethics has developed in both theory and practice mostly from experiences in medical research. Human participants, however, are used in a much broader range of research than ethics committees oversee, including both basic and applied research at technical universities. Although mandated in the United States, the United Kingdom, Canada, and Australia, non-medical research involving humans need not receive ethics review in much of Europe, Asia, Latin America, and Africa. Our survey of the top 50 technical universities in the world shows that, where not specifically mandated by law, most technical universities do not employ ethics committees to review human studies. As the domains of basic and applied sciences expand, ethics committees are increasingly needed to guide and oversee all such research regardless of legal requirements. We offer as examples, from our experience as an ethics committee in a major European technical university, ways in which such a committee provides needed services and can help ensure more ethical studies involving humans outside the standard medical context. We provide some arguments for creating such committees, and in our supplemental article, we provide specific examples of cases and concerns that may confront technical, engineering, and design research, as well as outline the general framework we have used in creating our committee. © The Author(s) 2014.

Compound Stimulus Presentation Does Not Deepen Extinction in Human Causal Learning

PubMed Central

Griffiths, Oren; Holmes, Nathan; Westbrook, R. Fred

2017-01-01

Models of associative learning have proposed that cue-outcome learning critically depends on the degree of prediction error encountered during training. Two experiments examined the role of error-driven extinction learning in a human causal learning task. Target cues underwent extinction in the presence of additional cues, which differed in the degree to which they predicted the outcome, thereby manipulating outcome expectancy and, in the absence of any change in reinforcement, prediction error. These prediction error manipulations have each been shown to modulate extinction learning in aversive conditioning studies. While both manipulations resulted in increased prediction error during training, neither enhanced extinction in the present human learning task (one manipulation resulted in less extinction at test). The results are discussed with reference to the types of associations that are regulated by prediction error, the types of error terms involved in their regulation, and how these interact with parameters involved in training. PMID:28232809

Human errors and occupational injuries of older female workers in the residential healthcare facilities for the elderly.

PubMed

Kim, Jun Sik; Jeong, Byung Yong

2018-05-03

The study aimed to describe the characteristics of occupational injuries of female workers in the residential healthcare facilities for the elderly, and analyze human errors as causes of accidents. From the national industrial accident compensation data, 506 female injuries were analyzed by age and occupation. The results showed that medical service worker was the most prevalent (54.1%), followed by social welfare worker (20.4%). Among injuries, 55.7% were <1 year of work experience, and 37.9% were ≥60 years old. Slips/falls were the most common type of accident (42.7%), and proportion of injured by slips/falls increases with age. Among human errors, action errors were the primary reasons, followed by perception errors, and cognition errors. Besides, the ratios of injuries by perception errors and action errors increase with age, respectively. The findings of this study suggest that there is a need to design workplaces that accommodate the characteristics of older female workers.

Pedal error crashes : traffic tech.

DOT National Transportation Integrated Search

2012-04-01

This project examined the prevalence of crashes in which the : driver pressed the accelerator pedal when he or she intended : to press the brake pedal, and the characteristics associated with : these crashes. : Technical literature published between ...

Informatics and data quality at collaborative multicenter Breast and Colon Cancer Family Registries.

PubMed

McGarvey, Peter B; Ladwa, Sweta; Oberti, Mauricio; Dragomir, Anca Dana; Hedlund, Erin K; Tanenbaum, David Michael; Suzek, Baris E; Madhavan, Subha

2012-06-01

Quality control and harmonization of data is a vital and challenging undertaking for any successful data coordination center and a responsibility shared between the multiple sites that produce, integrate, and utilize the data. Here we describe a coordinated effort between scientists and data managers in the Cancer Family Registries to implement a data governance infrastructure consisting of both organizational and technical solutions. The technical solution uses a rule-based validation system that facilitates error detection and correction for data centers submitting data to a central informatics database. Validation rules comprise both standard checks on allowable values and a crosscheck of related database elements for logical and scientific consistency. Evaluation over a 2-year timeframe showed a significant decrease in the number of errors in the database and a concurrent increase in data consistency and accuracy.

Informatics and data quality at collaborative multicenter Breast and Colon Cancer Family Registries

PubMed Central

McGarvey, Peter B; Ladwa, Sweta; Oberti, Mauricio; Dragomir, Anca Dana; Hedlund, Erin K; Tanenbaum, David Michael; Suzek, Baris E

2012-01-01

Quality control and harmonization of data is a vital and challenging undertaking for any successful data coordination center and a responsibility shared between the multiple sites that produce, integrate, and utilize the data. Here we describe a coordinated effort between scientists and data managers in the Cancer Family Registries to implement a data governance infrastructure consisting of both organizational and technical solutions. The technical solution uses a rule-based validation system that facilitates error detection and correction for data centers submitting data to a central informatics database. Validation rules comprise both standard checks on allowable values and a crosscheck of related database elements for logical and scientific consistency. Evaluation over a 2-year timeframe showed a significant decrease in the number of errors in the database and a concurrent increase in data consistency and accuracy. PMID:22323393

A Decision Support Tool to Evaluate Sources and Sinks of Nitrogen within a Watershed Framework

EPA Science Inventory

Human transformation of the nitrogen (N) cycle is causing a number of environmental and human health problems. Federal, state and local authorities focusing on management of N loadings face both technical and non-technical challenges. One technical issue is that we need a bette...

Basic Studies on High Pressure Air Plasmas

DTIC Science & Technology

2006-08-30

which must be added a 1.5 month salary to A. Bugayev for assistance in laser and optic techniques. 2 Part II Technical report Plasma-induced phase shift...two-wavelength heterodyne interferometry applied to atmospheric pressure air plasma 11.1 .A. Plasma-induced phase shift - Electron density...a driver, since the error on the frequency leads to an error on the phase shift. (c) Optical elements Mirrors Protected mirrors must be used to stand

The Humanities in the Two-Year Agricultural Technical College.

ERIC Educational Resources Information Center

Nelson, Ronald J.

Drawing from the experiences of the University of Minnesota Technical College, Waseca (UMW), this paper provides a rationale and suggestions for promoting and integrating the humanities in vocational education. After discussions of the problems of interesting occupational students in humanities courses and the value of humanities instruction in…

Experimental determination of the navigation error of the 4-D navigation, guidance, and control systems on the NASA B-737 airplane

NASA Technical Reports Server (NTRS)

Knox, C. E.

1978-01-01

Navigation error data from these flights are presented in a format utilizing three independent axes - horizontal, vertical, and time. The navigation position estimate error term and the autopilot flight technical error term are combined to form the total navigation error in each axis. This method of error presentation allows comparisons to be made between other 2-, 3-, or 4-D navigation systems and allows experimental or theoretical determination of the navigation error terms. Position estimate error data are presented with the navigation system position estimate based on dual DME radio updates that are smoothed with inertial velocities, dual DME radio updates that are smoothed with true airspeed and magnetic heading, and inertial velocity updates only. The normal mode of navigation with dual DME updates that are smoothed with inertial velocities resulted in a mean error of 390 m with a standard deviation of 150 m in the horizontal axis; a mean error of 1.5 m low with a standard deviation of less than 11 m in the vertical axis; and a mean error as low as 252 m with a standard deviation of 123 m in the time axis.

Laparoscopic skills suffer on the first shift of sequential night shifts: program directors beware and residents prepare.

PubMed

Leff, Daniel R; Aggarwal, Rajesh; Rana, Mariam; Nakhjavani, Batool; Purkayastha, Sanjay; Khullar, Vik; Darzi, Ara W

2008-03-01

Research evaluating fatigue-induced skills decline has focused on acute sleep deprivation rather than the effects of circadian desynchronization associated with multiple shifts. As a result, the number of consecutive night shifts that residents can safely be on duty without detrimental effects to their technical skills remains unknown. A prospective observational cohort study was conducted to assess the impact of 7 successive night shifts on the technical surgical performance of junior residents. The interventional strategy included training 21 residents from surgery and allied disciplines on a virtual reality surgical simulator, towards the achievement of preset benchmark scores, followed by 294 technical skills assessments conducted over 1764 manpower night shift hours. Primary outcomes comprised serial technical skills assessments on 2 tasks of a virtual reality surgical simulator. Secondary outcomes included assessments of introspective fatigue, duration of sleep, and prospective recordings of activity (number of "calls" received, steps walked, and patients evaluated). Maximal deterioration in performance was observed following the first night shift. Residents took significantly longer to complete the first (P = 0.002) and second tasks (P = 0.005) compared with baseline. They also committed significantly greater numbers of errors (P = 0.025) on the first task assessed. Improved performance was observed across subsequent shifts towards baseline levels. Newly acquired technical surgical skills deteriorate maximally after the first night shift, emphasizing the importance of adequate preparation for night rotas. Performance improvements across successive shifts may be due to ongoing learning or adaptation to chronic fatigue. Further research should focus on assessments of both technical procedural skills and cognitive abilities to determine the rotas that best minimize errors and maximize patient safety.

[Risk and risk management in aviation].

PubMed

Müller, Manfred

2004-10-01

RISK MANAGEMENT: The large proportion of human errors in aviation accidents suggested the solution--at first sight brilliant--to replace the fallible human being by an "infallible" digitally-operating computer. However, even after the introduction of the so-called HITEC-airplanes, the factor human error still accounts for 75% of all accidents. Thus, if the computer is ruled out as the ultimate safety system, how else can complex operations involving quick and difficult decisions be controlled? OPTIMIZED TEAM INTERACTION/PARALLEL CONNECTION OF THOUGHT MACHINES: Since a single person is always "highly error-prone", support and control have to be guaranteed by a second person. The independent work of mind results in a safety network that more efficiently cushions human errors. NON-PUNITIVE ERROR MANAGEMENT: To be able to tackle the actual problems, the open discussion of intervened errors must not be endangered by the threat of punishment. It has been shown in the past that progress is primarily achieved by investigating and following up mistakes, failures and catastrophes shortly after they happened. HUMAN FACTOR RESEARCH PROJECT: A comprehensive survey showed the following result: By far the most frequent safety-critical situation (37.8% of all events) consists of the following combination of risk factors: 1. A complication develops. 2. In this situation of increased stress a human error occurs. 3. The negative effects of the error cannot be corrected or eased because there are deficiencies in team interaction on the flight deck. This means, for example, that a negative social climate has the effect of a "turbocharger" when a human error occurs. It needs to be pointed out that a negative social climate is not identical with a dispute. In many cases the working climate is burdened without the responsible person even noticing it: A first negative impression, too much or too little respect, contempt, misunderstandings, not expressing unclear concern, etc. can considerably reduce the efficiency of a team.

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.

Advancing Free Flight Through Human Factors: Workshop Report

DOT National Transportation Integrated Search

1995-08-01

This report describes the results of the Advancing Free Flight Through Human : Factors technical workshop held on June 20 and 21, 1995. The purpose of this : technical workshop was to begin the process of identifying and solving human : factors issue...

Spatial electromagnetic field intensity modelling of global system for mobile communication base stations in the Istanbul Technical University Ayazaga campus area.

PubMed

Boz, Kubra; Denli, Hayri Hakan

2018-05-07

The rapid development of the global system for mobile communication services and the consequent increased electromagnetic field (EMF) exposure to the human body have generated debate on the potential danger with respect to human health. The many research studies focused on this subject have, however, not provided any certain evidence about harmful consequences due to mobile communication systems. On the other hand, there are still views suggesting such exposure might affect the human body in different ways. To reduce such effects to a minimum, the International Commission on Non-Ionizing Radiation Protection (ICNIRP) has declared boundary values for the energy released by the base stations, which are the main source of the electromagnetic fields. These values are accepted by many countries in various parts of the world. The aim of this study was to create EMF intensity maps for the area covered by Istanbul Technical University (ITU) and find areas of potential risk with regard to health considering the current situation and future trends. In this study, the field intensities of electromagnetic signals issued at the frequencies of 900 and 1800 MHz were measured in V/m at 29 pre-specified survey points using a spectrum analyzer (Spectran HF-6065). Geographic information systems and spatial interpolation techniques were used to produce EMF intensity maps. Three different spatial interpolation methods, minimum mean square error, Radial Basis and Empirical Bayesian Kriging, were compared. The results were geographically analyzed and the measurements expressed as heat maps covering the study area. Using these maps, the values measured were compared with the EMF intensity standards issued by ICNIRP. The results showed that the exposure levels to the EMF intensities were all within the ICNIRP limits at the ITU study area. However, since the EMF intensity level with respect to human health is not known, it is not possible to confirm if these levels are safe or not.

Human error analysis of commercial aviation accidents: application of the Human Factors Analysis and Classification system (HFACS).

PubMed

Wiegmann, D A; Shappell, S A

2001-11-01

The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents. Based on Reason's (1990) model of latent and active failures, HFACS addresses human error at all levels of the system, including the condition of aircrew and organizational factors. The purpose of the present study was to assess the utility of the HFACS framework as an error analysis and classification tool outside the military. The HFACS framework was used to analyze human error data associated with aircrew-related commercial aviation accidents that occurred between January 1990 and December 1996 using database records maintained by the NTSB and the FAA. Investigators were able to reliably accommodate all the human causal factors associated with the commercial aviation accidents examined in this study using the HFACS system. In addition, the classification of data using HFACS highlighted several critical safety issues in need of intervention research. These results demonstrate that the HFACS framework can be a viable tool for use within the civil aviation arena. However, additional research is needed to examine its applicability to areas outside the flight deck, such as aircraft maintenance and air traffic control domains.

To Err Is Human; To Structurally Prime from Errors Is Also Human

ERIC Educational Resources Information Center

Slevc, L. Robert; Ferreira, Victor S.

2013-01-01

Natural language contains disfluencies and errors. Do listeners simply discard information that was clearly produced in error, or can erroneous material persist to affect subsequent processing? Two experiments explored this question using a structural priming paradigm. Speakers described dative-eliciting pictures after hearing prime sentences that…

10 CFR 26.167 - Quality assurance and quality control.

Code of Federal Regulations, 2012 CFR

2012-01-01

... be designed, implemented, and reviewed to monitor the conduct of each step of the testing process. (b... sample and the error is determined to be technical or methodological, the licensee or other entity shall...

10 CFR 26.167 - Quality assurance and quality control.

Code of Federal Regulations, 2011 CFR

2011-01-01

... be designed, implemented, and reviewed to monitor the conduct of each step of the testing process. (b... sample and the error is determined to be technical or methodological, the licensee or other entity shall...

10 CFR 26.167 - Quality assurance and quality control.

Code of Federal Regulations, 2014 CFR

2014-01-01

... be designed, implemented, and reviewed to monitor the conduct of each step of the testing process. (b... sample and the error is determined to be technical or methodological, the licensee or other entity shall...

10 CFR 26.167 - Quality assurance and quality control.

Code of Federal Regulations, 2010 CFR

2010-01-01

... be designed, implemented, and reviewed to monitor the conduct of each step of the testing process. (b... sample and the error is determined to be technical or methodological, the licensee or other entity shall...

10 CFR 26.167 - Quality assurance and quality control.

Code of Federal Regulations, 2013 CFR

2013-01-01

... be designed, implemented, and reviewed to monitor the conduct of each step of the testing process. (b... sample and the error is determined to be technical or methodological, the licensee or other entity shall...

Analysis of localizer and glide slope Flight Technical Error

DOT National Transportation Integrated Search

2008-12-09

A new wake turbulence procedure has been developed that permits two dependent arrival traffic streams during instrument meteorological conditions : to runways with centerline separations less than 2500 ft. For the proposed procedure, aircraft approac...

Human factors analysis and classification system-HFACS.

DOT National Transportation Integrated Search

2000-02-01

Human error has been implicated in 70 to 80% of all civil and military aviation accidents. Yet, most accident : reporting systems are not designed around any theoretical framework of human error. As a result, most : accident databases are not conduci...

21 CFR 14.160 - Establishment of standing technical advisory committees for human prescription drugs.

Code of Federal Regulations, 2011 CFR

2011-04-01

... committees for human prescription drugs. 14.160 Section 14.160 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PUBLIC HEARING BEFORE A PUBLIC ADVISORY COMMITTEE Advisory Committees for Human Prescription Drugs § 14.160 Establishment of standing technical advisory committees for...

21 CFR 14.160 - Establishment of standing technical advisory committees for human prescription drugs.

Code of Federal Regulations, 2014 CFR

2014-04-01

... committees for human prescription drugs. 14.160 Section 14.160 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PUBLIC HEARING BEFORE A PUBLIC ADVISORY COMMITTEE Advisory Committees for Human Prescription Drugs § 14.160 Establishment of standing technical advisory committees for...

21 CFR 14.160 - Establishment of standing technical advisory committees for human prescription drugs.

Code of Federal Regulations, 2012 CFR

2012-04-01

... committees for human prescription drugs. 14.160 Section 14.160 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PUBLIC HEARING BEFORE A PUBLIC ADVISORY COMMITTEE Advisory Committees for Human Prescription Drugs § 14.160 Establishment of standing technical advisory committees for...

Security in Full-Force

NASA Technical Reports Server (NTRS)

2002-01-01

When fully developed for NASA, Vanguard Enforcer(TM) software-which emulates the activities of highly technical security system programmers, auditors, and administrators-was among the first intrusion detection programs to restrict human errors from affecting security, and to ensure the integrity of a computer's operating systems, as well as the protection of mission critical resources. Vanguard Enforcer was delivered in 1991 to Johnson Space Center and has been protecting systems and critical data there ever since. In August of 1999, NASA granted Vanguard exclusive rights to commercialize the Enforcer system for the private sector. In return, Vanguard continues to supply NASA with ongoing research, development, and support of Enforcer. The Vanguard Enforcer 4.2 is one of several surveillance technologies that make up the Vanguard Security Solutions line of products. Using a mainframe environment, Enforcer 4.2 achieves previously unattainable levels of automated security management.

The Training, Retention, and Assessment of Digital Skills: A Review and Integration of the Literature

DTIC Science & Technology

2006-11-01

Staff, G1 Authorized and approved for distribution: STANLEY M. HALPIN MICHELLE SAMS Acting Technical Director Acting Director Technical review by...research has found some benefit for spacing practice for motor skills. In an investigation of fuel and electrical repairers who were trained to test... electrical alternators using either massed or spaced training, the spaced training group made 40% fewer errors and took half the time to complete the tasks

Technical Issues in Evolving to Integrated Services Digital Network (ISDN)

DTIC Science & Technology

1991-06-01

channel through some Page 13 Technical Issues in Evolving to ISDN Final Report separate interface (such as the AT command set of the Hayes modems or the...errors experienced over standard modem provided connectivity. But, in this project connectivity has been established only over a single CO. Those...examined to some extent and are discussed below. Existing equipment was of two types: that which treats ISDN as just another leased line providing 56k or

Contextual Sensing: Integrating Contextual Information with Human and Technical Geo-Sensor Information for Smart Cities

PubMed Central

Sagl, Günther; Resch, Bernd; Blaschke, Thomas

2015-01-01

In this article we critically discuss the challenge of integrating contextual information, in particular spatiotemporal contextual information, with human and technical sensor information, which we approach from a geospatial perspective. We start by highlighting the significance of context in general and spatiotemporal context in particular and introduce a smart city model of interactions between humans, the environment, and technology, with context at the common interface. We then focus on both the intentional and the unintentional sensing capabilities of today’s technologies and discuss current technological trends that we consider have the ability to enrich human and technical geo-sensor information with contextual detail. The different types of sensors used to collect contextual information are analyzed and sorted into three groups on the basis of names considering frequently used related terms, and characteristic contextual parameters. These three groups, namely technical in situ sensors, technical remote sensors, and human sensors are analyzed and linked to three dimensions involved in sensing (data generation, geographic phenomena, and type of sensing). In contrast to other scientific publications, we found a large number of technologies and applications using in situ and mobile technical sensors within the context of smart cities, and surprisingly limited use of remote sensing approaches. In this article we further provide a critical discussion of possible impacts and influences of both technical and human sensing approaches on society, pointing out that a larger number of sensors, increased fusion of information, and the use of standardized data formats and interfaces will not necessarily result in any improvement in the quality of life of the citizens of a smart city. This article seeks to improve our understanding of technical and human geo-sensing capabilities, and to demonstrate that the use of such sensors can facilitate the integration of different types of contextual information, thus providing an additional, namely the geo-spatial perspective on the future development of smart cities. PMID:26184221

Contextual Sensing: Integrating Contextual Information with Human and Technical Geo-Sensor Information for Smart Cities.

PubMed

Sagl, Günther; Resch, Bernd; Blaschke, Thomas

2015-07-14

In this article we critically discuss the challenge of integrating contextual information, in particular spatiotemporal contextual information, with human and technical sensor information, which we approach from a geospatial perspective. We start by highlighting the significance of context in general and spatiotemporal context in particular and introduce a smart city model of interactions between humans, the environment, and technology, with context at the common interface. We then focus on both the intentional and the unintentional sensing capabilities of today's technologies and discuss current technological trends that we consider have the ability to enrich human and technical geo-sensor information with contextual detail. The different types of sensors used to collect contextual information are analyzed and sorted into three groups on the basis of names considering frequently used related terms, and characteristic contextual parameters. These three groups, namely technical in situ sensors, technical remote sensors, and human sensors are analyzed and linked to three dimensions involved in sensing (data generation, geographic phenomena, and type of sensing). In contrast to other scientific publications, we found a large number of technologies and applications using in situ and mobile technical sensors within the context of smart cities, and surprisingly limited use of remote sensing approaches. In this article we further provide a critical discussion of possible impacts and influences of both technical and human sensing approaches on society, pointing out that a larger number of sensors, increased fusion of information, and the use of standardized data formats and interfaces will not necessarily result in any improvement in the quality of life of the citizens of a smart city. This article seeks to improve our understanding of technical and human geo-sensing capabilities, and to demonstrate that the use of such sensors can facilitate the integration of different types of contextual information, thus providing an additional, namely the geo-spatial perspective on the future development of smart cities.

The dynamics of error processing in the human brain as reflected by high-gamma activity in noninvasive and intracranial EEG.

PubMed

Völker, Martin; Fiederer, Lukas D J; Berberich, Sofie; Hammer, Jiří; Behncke, Joos; Kršek, Pavel; Tomášek, Martin; Marusič, Petr; Reinacher, Peter C; Coenen, Volker A; Helias, Moritz; Schulze-Bonhage, Andreas; Burgard, Wolfram; Ball, Tonio

2018-06-01

Error detection in motor behavior is a fundamental cognitive function heavily relying on local cortical information processing. Neural activity in the high-gamma frequency band (HGB) closely reflects such local cortical processing, but little is known about its role in error processing, particularly in the healthy human brain. Here we characterize the error-related response of the human brain based on data obtained with noninvasive EEG optimized for HGB mapping in 31 healthy subjects (15 females, 16 males), and additional intracranial EEG data from 9 epilepsy patients (4 females, 5 males). Our findings reveal a multiscale picture of the global and local dynamics of error-related HGB activity in the human brain. On the global level as reflected in the noninvasive EEG, the error-related response started with an early component dominated by anterior brain regions, followed by a shift to parietal regions, and a subsequent phase characterized by sustained parietal HGB activity. This phase lasted for more than 1 s after the error onset. On the local level reflected in the intracranial EEG, a cascade of both transient and sustained error-related responses involved an even more extended network, spanning beyond frontal and parietal regions to the insula and the hippocampus. HGB mapping appeared especially well suited to investigate late, sustained components of the error response, possibly linked to downstream functional stages such as error-related learning and behavioral adaptation. Our findings establish the basic spatio-temporal properties of HGB activity as a neural correlate of error processing, complementing traditional error-related potential studies. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

The most common mistakes on dermatoscopy of melanocytic lesions

PubMed Central

Kamińska-Winciorek, Grażyna

2015-01-01

Dermatoscopy is a method of in vivo evaluation of the structures within the epidermis and dermis. Currently, it may be the most precise pre-surgical method of diagnosing melanocytic lesions. Diagnostic errors may result in unnecessary removal of benign lesions or what is even worse, they can cause early and very early melanomas to be overlooked. Errors in assessment of dermatoscopy can be divided into those arising from failure to maintain proper test procedures (procedural and technical errors) and knowledge based mistakes related to the lack of sufficient familiarity and experience in dermatoscopy. The article discusses the most common mistakes made by beginner or inexperienced dermatoscopists. PMID:25821425

Development of an errorable car-following driver model

NASA Astrophysics Data System (ADS)

Yang, H.-H.; Peng, H.

2010-06-01

An errorable car-following driver model is presented in this paper. An errorable driver model is one that emulates human driver's functions and can generate both nominal (error-free), as well as devious (with error) behaviours. This model was developed for evaluation and design of active safety systems. The car-following data used for developing and validating the model were obtained from a large-scale naturalistic driving database. The stochastic car-following behaviour was first analysed and modelled as a random process. Three error-inducing behaviours were then introduced. First, human perceptual limitation was studied and implemented. Distraction due to non-driving tasks was then identified based on the statistical analysis of the driving data. Finally, time delay of human drivers was estimated through a recursive least-square identification process. By including these three error-inducing behaviours, rear-end collisions with the lead vehicle could occur. The simulated crash rate was found to be similar but somewhat higher than that reported in traffic statistics.

Lost in Translation: the Case for Integrated Testing

NASA Technical Reports Server (NTRS)

Young, Aaron

2017-01-01

The building of a spacecraft is complex and often involves multiple suppliers and companies that have their own designs and processes. Standards have been developed across the industries to reduce the chances for critical flight errors at the system level, but the spacecraft is still vulnerable to the introduction of critical errors during integration of these systems. Critical errors can occur at any time during the process and in many cases, human reliability analysis (HRA) identifies human error as a risk driver. Most programs have a test plan in place that is intended to catch these errors, but it is not uncommon for schedule and cost stress to result in less testing than initially planned. Therefore, integrated testing, or "testing as you fly," is essential as a final check on the design and assembly to catch any errors prior to the mission. This presentation will outline the unique benefits of integrated testing by catching critical flight errors that can otherwise go undetected, discuss HRA methods that are used to identify opportunities for human error, lessons learned and challenges over ownership of testing will be discussed.

Human factors in aircraft incidents - Results of a 7-year study (Andre Allard Memorial Lecture)

NASA Technical Reports Server (NTRS)

Billings, C. E.; Reynard, W. D.

1984-01-01

It is pointed out that nearly all fatal aircraft accidents are preventable, and that most such accidents are due to human error. The present discussion is concerned with the results of a seven-year study of the data collected by the NASA Aviation Safety Reporting System (ASRS). The Aviation Safety Reporting System was designed to stimulate as large a flow as possible of information regarding errors and operational problems in the conduct of air operations. It was implemented in April, 1976. In the following 7.5 years, 35,000 reports have been received from pilots, controllers, and the armed forces. Human errors are found in more than 80 percent of these reports. Attention is given to the types of events reported, possible causal factors in incidents, the relationship of incidents and accidents, and sources of error in the data. ASRS reports include sufficient detail to permit authorities to institute changes in the national aviation system designed to minimize the likelihood of human error, and to insulate the system against the effects of errors.

AstrodyToolsWeb an e-Science project in Astrodynamics and Celestial Mechanics fields

NASA Astrophysics Data System (ADS)

López, R.; San-Juan, J. F.

2013-05-01

Astrodynamics Web Tools, AstrodyToolsWeb (http://tastrody.unirioja.es), is an ongoing collaborative Web Tools computing infrastructure project which has been specially designed to support scientific computation. AstrodyToolsWeb provides project collaborators with all the technical and human facilities in order to wrap, manage, and use specialized noncommercial software tools in Astrodynamics and Celestial Mechanics fields, with the aim of optimizing the use of resources, both human and material. However, this project is open to collaboration from the whole scientific community in order to create a library of useful tools and their corresponding theoretical backgrounds. AstrodyToolsWeb offers a user-friendly web interface in order to choose applications, introduce data, and select appropriate constraints in an intuitive and easy way for the user. After that, the application is executed in real time, whenever possible; then the critical information about program behavior (errors and logs) and output, including the postprocessing and interpretation of its results (graphical representation of data, statistical analysis or whatever manipulation therein), are shown via the same web interface or can be downloaded to the user's computer.

Publisher Correction: Measuring progress from nationally determined contributions to mid-century strategies

NASA Astrophysics Data System (ADS)

Iyer, Gokul; Ledna, Catherine; Clarke, Leon; Edmonds, James; McJeon, Haewon; Kyle, Page; Williams, James H.

2018-03-01

In the version of this Article previously published, technical problems led to the wrong summary appearing on the homepage, and an incorrect Supplementary Information file being uploaded. Both errors have now been corrected.

The Human Factors Analysis and Classification System : HFACS : final report.

DOT National Transportation Integrated Search

2000-02-01

Human error has been implicated in 70 to 80% of all civil and military aviation accidents. Yet, most accident reporting systems are not designed around any theoretical framework of human error. As a result, most accident databases are not conducive t...

Differential reliance of chimpanzees and humans on automatic and deliberate control of motor actions.

PubMed

Kaneko, Takaaki; Tomonaga, Masaki

2014-06-01

Humans are often unaware of how they control their limb motor movements. People pay attention to their own motor movements only when their usual motor routines encounter errors. Yet little is known about the extent to which voluntary actions rely on automatic control and when automatic control shifts to deliberate control in nonhuman primates. In this study, we demonstrate that chimpanzees and humans showed similar limb motor adjustment in response to feedback error during reaching actions, whereas attentional allocation inferred from gaze behavior differed. We found that humans shifted attention to their own motor kinematics as errors were induced in motor trajectory feedback regardless of whether the errors actually disrupted their reaching their action goals. In contrast, chimpanzees shifted attention to motor execution only when errors actually interfered with their achieving a planned action goal. These results indicate that the species differed in their criteria for shifting from automatic to deliberate control of motor actions. It is widely accepted that sophisticated motor repertoires have evolved in humans. Our results suggest that the deliberate monitoring of one's own motor kinematics may have evolved in the human lineage. Copyright © 2014 Elsevier B.V. All rights reserved.

Decision making in urological surgery.

PubMed

Abboudi, Hamid; Ahmed, Kamran; Normahani, Pasha; Abboudi, May; Kirby, Roger; Challacombe, Ben; Khan, Mohammed Shamim; Dasgupta, Prokar

2012-06-01

Non-technical skills are important behavioural aspects that a urologist must be fully competent at to minimise harm to patients. The majority of surgical errors are now known to be due to errors in judgment and decision making as opposed to the technical aspects of the craft. The authors reviewed the published literature regarding decision-making theory and in practice related to urology as well as the current tools available to assess decision-making skills. Limitations include limited number of studies, and the available studies are of low quality. Decision making is the psychological process of choosing between alternative courses of action. In the surgical environment, this can often be a complex balance of benefit and risk within a variable time frame and dynamic setting. In recent years, the emphasis of new surgical curriculums has shifted towards non-technical surgical skills; however, the assessment tools in place are far from objective, reliable and valid. Surgical simulators and video-assisted questionnaires are useful methods for appraisal of trainees. Well-designed, robust and validated tools need to be implemented in training and assessment of decision-making skills in urology. Patient safety can only be ensured when safe and effective decisions are made.

Using Model-Based Systems Engineering To Provide Artifacts for NASA Project Life-Cycle and Technical Reviews

NASA Technical Reports Server (NTRS)

Parrott, Edith L.; Weiland, Karen J.

2017-01-01

The ability of systems engineers to use model-based systems engineering (MBSE) to generate self-consistent, up-to-date systems engineering products for project life-cycle and technical reviews is an important aspect for the continued and accelerated acceptance of MBSE. Currently, many review products are generated using labor-intensive, error-prone approaches based on documents, spreadsheets, and chart sets; a promised benefit of MBSE is that users will experience reductions in inconsistencies and errors. This work examines features of SysML that can be used to generate systems engineering products. Model elements, relationships, tables, and diagrams are identified for a large number of the typical systems engineering artifacts. A SysML system model can contain and generate most systems engineering products to a significant extent and this paper provides a guide on how to use MBSE to generate products for project life-cycle and technical reviews. The use of MBSE can reduce the schedule impact usually experienced for review preparation, as in many cases the review products can be auto-generated directly from the system model. These approaches are useful to systems engineers, project managers, review board members, and other key project stakeholders.

Preventable Medical Errors Driven Modeling of Medical Best Practice Guidance Systems.

PubMed

Ou, Andrew Y-Z; Jiang, Yu; Wu, Po-Liang; Sha, Lui; Berlin, Richard B

2017-01-01

In a medical environment such as Intensive Care Unit, there are many possible reasons to cause errors, and one important reason is the effect of human intellectual tasks. When designing an interactive healthcare system such as medical Cyber-Physical-Human Systems (CPHSystems), it is important to consider whether the system design can mitigate the errors caused by these tasks or not. In this paper, we first introduce five categories of generic intellectual tasks of humans, where tasks among each category may lead to potential medical errors. Then, we present an integrated modeling framework to model a medical CPHSystem and use UPPAAL as the foundation to integrate and verify the whole medical CPHSystem design models. With a verified and comprehensive model capturing the human intellectual tasks effects, we can design a more accurate and acceptable system. We use a cardiac arrest resuscitation guidance and navigation system (CAR-GNSystem) for such medical CPHSystem modeling. Experimental results show that the CPHSystem models help determine system design flaws and can mitigate the potential medical errors caused by the human intellectual tasks.

Quantum error correction assisted by two-way noisy communication

PubMed Central

Wang, Zhuo; Yu, Sixia; Fan, Heng; Oh, C. H.

2014-01-01

Pre-shared non-local entanglement dramatically simplifies and improves the performance of quantum error correction via entanglement-assisted quantum error-correcting codes (EAQECCs). However, even considering the noise in quantum communication only, the non-local sharing of a perfectly entangled pair is technically impossible unless additional resources are consumed, such as entanglement distillation, which actually compromises the efficiency of the codes. Here we propose an error-correcting protocol assisted by two-way noisy communication that is more easily realisable: all quantum communication is subjected to general noise and all entanglement is created locally without additional resources consumed. In our protocol the pre-shared noisy entangled pairs are purified simultaneously by the decoding process. For demonstration, we first present an easier implementation of the well-known EAQECC [[4, 1, 3; 1

Quantum error correction assisted by two-way noisy communication.

PubMed

Wang, Zhuo; Yu, Sixia; Fan, Heng; Oh, C H

2014-11-26

Pre-shared non-local entanglement dramatically simplifies and improves the performance of quantum error correction via entanglement-assisted quantum error-correcting codes (EAQECCs). However, even considering the noise in quantum communication only, the non-local sharing of a perfectly entangled pair is technically impossible unless additional resources are consumed, such as entanglement distillation, which actually compromises the efficiency of the codes. Here we propose an error-correcting protocol assisted by two-way noisy communication that is more easily realisable: all quantum communication is subjected to general noise and all entanglement is created locally without additional resources consumed. In our protocol the pre-shared noisy entangled pairs are purified simultaneously by the decoding process. For demonstration, we first present an easier implementation of the well-known EAQECC [[4, 1, 3; 1

CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE QUALITY OF DXA SCANS AND REPORTS.

PubMed

Licata, Angelo A; Binkley, Neil; Petak, Steven M; Camacho, Pauline M

2018-02-01

High-quality dual-energy X-ray absorptiometry (DXA) scans are necessary for accurate diagnosis of osteoporosis and monitoring of therapy; however, DXA scan reports may contain errors that cause confusion about diagnosis and treatment. This American Association of Clinical Endocrinologists/American College of Endocrinology consensus statement was generated to draw attention to many common technical problems affecting DXA report conclusions and provide guidance on how to address them to ensure that patients receive appropriate osteoporosis care. The DXA Writing Committee developed a consensus based on discussion and evaluation of available literature related to osteoporosis and osteodensitometry. Technical errors may include errors in scan acquisition and/or analysis, leading to incorrect diagnosis and reporting of change over time. Although the International Society for Clinical Densitometry advocates training for technologists and medical interpreters to help eliminate these problems, many lack skill in this technology. Suspicion that reports are wrong arises when clinical history is not compatible with scan interpretation (e.g., dramatic increase/decrease in a short period of time; declines in previously stable bone density after years of treatment), when different scanners are used, or when inconsistent anatomic sites are used for monitoring the response to therapy. Understanding the concept of least significant change will minimize erroneous conclusions about changes in bone density. Clinicians must develop the skills to differentiate technical problems, which confound reports, from real biological changes. We recommend that clinicians review actual scan images and data, instead of relying solely on the impression of the report, to pinpoint errors and accurately interpret DXA scan images. AACE = American Association of Clinical Endocrinologists; BMC = bone mineral content; BMD = bone mineral density; DXA = dual-energy X-ray absorptiometry; ISCD = International Society for Clinical Densitometry; LSC = least significant change; TBS = trabecular bone score; WHO = World Health Organization.

Randomized controlled trial of multidisciplinary team stress and performance in immersive simulation for management of infant in shock: study protocol.

PubMed

Ghazali, Daniel Aiham; Ragot, Stéphanie; Breque, Cyril; Guechi, Youcef; Boureau-Voultoury, Amélie; Petitpas, Franck; Oriot, Denis

2016-03-25

Human error and system failures continue to play a substantial role in adverse outcomes in healthcare. Simulation improves management of patients in critical condition, especially if it is undertaken by a multidisciplinary team. It covers technical skills (technical and therapeutic procedures) and non-technical skills, known as Crisis Resource Management. The relationship between stress and performance is theoretically described by the Yerkes-Dodson law as an inverted U-shaped curve. Performance is very low for a low level of stress and increases with an increased level of stress, up to a point, after which performance decreases and becomes severely impaired. The objectives of this randomized trial are to study the effect of stress on performance and the effect of repeated simulation sessions on performance and stress. This study is a single-center, investigator-initiated randomized controlled trial including 48 participants distributed in 12 multidisciplinary teams. Each team is made up of 4 persons: an emergency physician, a resident, a nurse, and an ambulance driver who usually constitute a French Emergency Medical Service team. Six multidisciplinary teams are planning to undergo 9 simulation sessions over 1 year (experimental group), and 6 multidisciplinary teams are planning to undergo 3 simulation sessions over 1 year (control group). Evidence of the existence of stress will be assessed according to 3 criteria: biological, electrophysiological, and psychological stress. The impact of stress on overall team performance, technical procedure and teamwork will be evaluated. Participant self-assessment of the perceived impact of simulations on clinical practice will be collected. Detection of post-traumatic stress disorder will be performed by self-assessment questionnaire on the 7(th) day and after 1 month. We will concomitantly evaluate technical and non-technical performance, and the impact of stress on both. This is the first randomized trial studying repetition of simulation sessions and its impact on both clinical performance and stress, which is explored by objective and subjective assessments. We expect that stress decreases team performance and that repeated simulation will increase it. We expect no variation of stress parameters regardless of the level of performance. ClinicalTrials.gov registration number NCT02424890.

Endoscopic non-technical skills team training: the next step in quality assurance of endoscopy training.

PubMed

Matharoo, Manmeet; Haycock, Adam; Sevdalis, Nick; Thomas-Gibson, Siwan

2014-12-14

To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes. A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day's training utilising real clinical examples. Pre and post-course evaluation comprised participants' patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected. Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P ≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training. A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams' knowledge and safety attitudes.

Endoscopic non-technical skills team training: The next step in quality assurance of endoscopy training

PubMed Central

Matharoo, Manmeet; Haycock, Adam; Sevdalis, Nick; Thomas-Gibson, Siwan

2014-01-01

AIM: To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes. METHODS: A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day’s training utilising real clinical examples. Pre and post-course evaluation comprised participants’ patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected. RESULTS: Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P ≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training. CONCLUSION: A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams’ knowledge and safety attitudes. PMID:25516665

The Consolidated Human Activity Database — Master Version (CHAD-Master) Technical Memorandum

EPA Pesticide Factsheets

This technical memorandum contains information about the Consolidated Human Activity Database -- Master version, including CHAD contents, inventory of variables: Questionnaire files and Event files, CHAD codes, and references.

Modeling human tracking error in several different anti-tank systems

NASA Technical Reports Server (NTRS)

Kleinman, D. L.

1981-01-01

An optimal control model for generating time histories of human tracking errors in antitank systems is outlined. Monte Carlo simulations of human operator responses for three Army antitank systems are compared. System/manipulator dependent data comparisons reflecting human operator limitations in perceiving displayed quantities and executing intended control motions are presented. Motor noise parameters are also discussed.

[Using some modern mathematical models of postmortem cooling of the human body for the time of death determination].

PubMed

Vavilov, A Iu; Viter, V I

2007-01-01

Mathematical questions of data errors of modern thermometrical models of postmortem cooling of the human body are considered. The main diagnostic areas used for thermometry are analyzed to minimize these data errors. The authors propose practical recommendations to decrease data errors of determination of prescription of death coming.

The Hinton train disaster.

PubMed

Smiley, A M

1990-10-01

In February of 1986 a head-on collision occurred between a freight train and a passenger train in western Canada killing 23 people and causing over $30 million of damage. A Commission of Inquiry appointed by the Canadian government concluded that human error was the major reason for the collision. This report discusses the factors contributing to the human error: mainly poor work-rest schedules, the monotonous nature of the train driving task, insufficient information about train movements, and the inadequate backup systems in case of human error.

A Conceptual Framework for Predicting Error in Complex Human-Machine Environments

NASA Technical Reports Server (NTRS)

Freed, Michael; Remington, Roger; Null, Cynthia H. (Technical Monitor)

1998-01-01

We present a Goals, Operators, Methods, and Selection Rules-Model Human Processor (GOMS-MHP) style model-based approach to the problem of predicting human habit capture errors. Habit captures occur when the model fails to allocate limited cognitive resources to retrieve task-relevant information from memory. Lacking the unretrieved information, decision mechanisms act in accordance with implicit default assumptions, resulting in error when relied upon assumptions prove incorrect. The model helps interface designers identify situations in which such failures are especially likely.

Nature of the refractive errors in rhesus monkeys (Macaca mulatta) with experimentally induced ametropias.

PubMed

Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-Su; Ramamirtham, Ramkumar; Smith, Earl L

2010-08-23

We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. Copyright 2010 Elsevier Ltd. All rights reserved.

Nature of the Refractive Errors in Rhesus Monkeys (Macaca mulatta) with Experimentally Induced Ametropias

PubMed Central

Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-su; Ramamirtham, Ramkumar; Smith, Earl L.

2010-01-01

We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. PMID:20600237

Fabricating CAD/CAM Implant-Retained Mandibular Bar Overdentures: A Clinical and Technical Overview.

PubMed

Goo, Chui Ling; Tan, Keson Beng Choon

2017-01-01

This report describes the clinical and technical aspects in the oral rehabilitation of an edentulous patient with knife-edge ridge at the mandibular anterior edentulous region, using implant-retained overdentures. The application of computer-aided design and computer-aided manufacturing (CAD/CAM) in the fabrication of the overdenture framework simplifies the laboratory process of the implant prostheses. The Nobel Procera CAD/CAM System was utilised to produce a lightweight titanium overdenture bar with locator attachments. It is proposed that the digital workflow of CAD/CAM milled implant overdenture bar allows us to avoid numerous technical steps and possibility of casting errors involved in the conventional casting of such bars.

Exploration studies technical report, FY1988 status. Volume 1: Technical summary

NASA Technical Reports Server (NTRS)

1988-01-01

The Office of Exploration (OEXP) at NASA Headquarters has been tasked with defining and recommending alternatives for an early 1990's nationaL decision on a focused program of human exploration of the solar system. The Mission Analysis and System Engineering (MASE) group, which is managed by the Exploration Studies Office at the Lyndon B. Johnson Space Center, is responsible for coordinating the technical studies necessary for accomplishing such a task. This technical report, produced by the MASE, describes the process that has been developed in a case study approach. The four case studies developed in FY88 include: (1) Human Expedition to Phobos; (2) Human Expedition to Mars; (3) Lunar Observatory; and (4) Lunar Outpost to Early Mars Evolution. The final outcome of this effort is a set of programmatic and technical conclusions and recommendations for the following year's work.

Socio-Technical Deliberation about Free and Open Source Software: Accounting for the Status of Artifacts in Public Life

ERIC Educational Resources Information Center

Benoit-Barne, Chantal

2007-01-01

This essay investigates the rhetorical practices of socio-technical deliberation about free and open source (F/OS) software, providing support for the idea that a public sphere is a socio-technical ensemble that is discursive and fluid, yet tangible and organized because it is enacted by both humans and non-humans. In keeping with the empirical…

Automation in the Teaching of Descriptive Geometry and CAD. High-Level CAD Templates Using Script Languages

NASA Astrophysics Data System (ADS)

Moreno, R.; Bazán, A. M.

2017-10-01

The main purpose of this work is to study improvements to the learning method of technical drawing and descriptive geometry through exercises with traditional techniques that are usually solved manually by applying automated processes assisted by high-level CAD templates (HLCts). Given that an exercise with traditional procedures can be solved, detailed step by step in technical drawing and descriptive geometry manuals, CAD applications allow us to do the same and generalize it later, incorporating references. Traditional teachings have become obsolete and current curricula have been relegated. However, they can be applied in certain automation processes. The use of geometric references (using variables in script languages) and their incorporation into HLCts allows the automation of drawing processes. Instead of repeatedly creating similar exercises or modifying data in the same exercises, users should be able to use HLCts to generate future modifications of these exercises. This paper introduces the automation process when generating exercises based on CAD script files, aided by parametric geometry calculation tools. The proposed method allows us to design new exercises without user intervention. The integration of CAD, mathematics, and descriptive geometry facilitates their joint learning. Automation in the generation of exercises not only saves time but also increases the quality of the statements and reduces the possibility of human error.

Currie detection limits in gamma-ray spectroscopy.

PubMed

De Geer, Lars-Erik

2004-01-01

Currie Hypothesis testing is applied to gamma-ray spectral data, where an optimum part of the peak is used and the background is considered well known from nearby channels. With this, the risk of making Type I errors is about 100 times lower than commonly assumed. A programme, PeakMaker, produces random peaks with given characteristics on the screen and calculations are done to facilitate a full use of Poisson statistics in spectrum analyses. SHORT TECHNICAL NOTE SUMMARY: The Currie decision limit concept applied to spectral data is reinterpreted, which gives better consistency between the selected error risk and the observed error rates. A PeakMaker program is described and the few count problem is analyzed.

Publisher Correction: A molecular cross-linking approach for hybrid metal oxides

NASA Astrophysics Data System (ADS)

Jung, Dahee; Saleh, Liban M. A.; Berkson, Zachariah J.; El-Kady, Maher F.; Hwang, Jee Youn; Mohamed, Nahla; Wixtrom, Alex I.; Titarenko, Ekaterina; Shao, Yanwu; McCarthy, Kassandra; Guo, Jian; Martini, Ignacio B.; Kraemer, Stephan; Wegener, Evan C.; Saint-Cricq, Philippe; Ruehle, Bastian; Langeslay, Ryan R.; Delferro, Massimiliano; Brosmer, Jonathan L.; Hendon, Christopher H.; Gallagher-Jones, Marcus; Rodriguez, Jose; Chapman, Karena W.; Miller, Jeffrey T.; Duan, Xiangfeng; Kaner, Richard B.; Zink, Jeffrey I.; Chmelka, Bradley F.; Spokoyny, Alexander M.

2018-03-01

In the version of this Article originally published, Liban M. A. Saleh was incorrectly listed as Liban A. M. Saleh due to a technical error. This has now been amended in all online versions of the Article.

77 FR 72984 - Buprofezin Pesticide Tolerances; Technical Correction

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-07

... ENVIRONMENTAL PROTECTION AGENCY 40 CFR Part 180 [EPA-HQ-OPP-2011-0759; FRL-9371-3] Buprofezin..., 2012, concerning buprofezin pesticide tolerances. This document corrects a typographical error. DATES...: Sec. 180.511 Buprofezin; tolerances for residues. (a) * * * Parts per Commodity million...

Research on error control and compensation in magnetorheological finishing.

PubMed

Dai, Yifan; Hu, Hao; Peng, Xiaoqiang; Wang, Jianmin; Shi, Feng

2011-07-01

Although magnetorheological finishing (MRF) is a deterministic finishing technology, the machining results always fall short of simulation precision in the actual process, and it cannot meet the precision requirements just through a single treatment but after several iterations. We investigate the reasons for this problem through simulations and experiments. Through controlling and compensating the chief errors in the manufacturing procedure, such as removal function calculation error, positioning error of the removal function, and dynamic performance limitation of the CNC machine, the residual error convergence ratio (ratio of figure error before and after processing) in a single process is obviously increased, and higher figure precision is achieved. Finally, an improved technical process is presented based on these researches, and the verification experiment is accomplished on the experimental device we developed. The part is a circular plane mirror of fused silica material, and the surface figure error is improved from the initial λ/5 [peak-to-valley (PV) λ=632.8 nm], λ/30 [root-mean-square (rms)] to the final λ/40 (PV), λ/330 (rms) just through one iteration in 4.4 min. Results show that a higher convergence ratio and processing precision can be obtained by adopting error control and compensation techniques in MRF.

Research on measurement of aviation magneto ignition strength and balance

NASA Astrophysics Data System (ADS)

Gao, Feng; He, Zhixiang; Zhang, Dingpeng

2017-12-01

Aviation magneto ignition system failure accounted for two-thirds of the total fault aviation piston engine and above. At present the method used for this failure diagnosis is often depended on the visual inspections in the civil aviation maintenance field. Due to human factors, the visual inspections cannot provide ignition intensity value and ignition equilibrium deviation value among the different spark plugs in the different cylinder of aviation piston engine. So air magneto ignition strength and balance testing has become an aviation piston engine maintenance technical problem needed to resolve. In this paper, the ultraviolet sensor with detection wavelength of 185~260nm and driving voltage of 320V DC is used as the core of ultraviolet detection to detect the ignition intensity of Aviation magneto ignition system and the balance deviation of the ignition intensity of each cylinder. The experimental results show that the rotational speed within the range 0 to 3500 RPM test error less than 0.34%, ignition strength analysis and calculation error is less than 0.13%, and measured the visual inspection is hard to distinguish between high voltage wire leakage failure of deviation value of 200 pulse ignition strength balance/Sec. The method to detect aviation piston engine maintenance of magneto ignition system fault has a certain reference value.

Differential quantitative proteomics of Porphyromonas gingivalis by linear ion trap mass spectrometry: non-label methods comparison, q-values and LOWESS curve fitting

PubMed Central

Xia, Qiangwei; Wang, Tiansong; Park, Yoonsuk; Lamont, Richard J.; Hackett, Murray

2009-01-01

Differential analysis of whole cell proteomes by mass spectrometry has largely been applied using various forms of stable isotope labeling. While metabolic stable isotope labeling has been the method of choice, it is often not possible to apply such an approach. Four different label free ways of calculating expression ratios in a classic “two-state” experiment are compared: signal intensity at the peptide level, signal intensity at the protein level, spectral counting at the peptide level, and spectral counting at the protein level. The quantitative data were mined from a dataset of 1245 qualitatively identified proteins, about 56% of the protein encoding open reading frames from Porphyromonas gingivalis, a Gram-negative intracellular pathogen being studied under extracellular and intracellular conditions. Two different control populations were compared against P. gingivalis internalized within a model human target cell line. The q-value statistic, a measure of false discovery rate previously applied to transcription microarrays, was applied to proteomics data. For spectral counting, the most logically consistent estimate of random error came from applying the locally weighted scatter plot smoothing procedure (LOWESS) to the most extreme ratios generated from a control technical replicate, thus setting upper and lower bounds for the region of experimentally observed random error. PMID:19337574

ERASE-Seq: Leveraging replicate measurements to enhance ultralow frequency variant detection in NGS data

PubMed Central

Kamps-Hughes, Nick; McUsic, Andrew; Kurihara, Laurie; Harkins, Timothy T.; Pal, Prithwish; Ray, Claire

2018-01-01

The accurate detection of ultralow allele frequency variants in DNA samples is of interest in both research and medical settings, particularly in liquid biopsies where cancer mutational status is monitored from circulating DNA. Next-generation sequencing (NGS) technologies employing molecular barcoding have shown promise but significant sensitivity and specificity improvements are still needed to detect mutations in a majority of patients before the metastatic stage. To address this we present analytical validation data for ERASE-Seq (Elimination of Recurrent Artifacts and Stochastic Errors), a method for accurate and sensitive detection of ultralow frequency DNA variants in NGS data. ERASE-Seq differs from previous methods by creating a robust statistical framework to utilize technical replicates in conjunction with background error modeling, providing a 10 to 100-fold reduction in false positive rates compared to published molecular barcoding methods. ERASE-Seq was tested using spiked human DNA mixtures with clinically realistic DNA input quantities to detect SNVs and indels between 0.05% and 1% allele frequency, the range commonly found in liquid biopsy samples. Variants were detected with greater than 90% sensitivity and a false positive rate below 0.1 calls per 10,000 possible variants. The approach represents a significant performance improvement compared to molecular barcoding methods and does not require changing molecular reagents. PMID:29630678

Reducing non-collision injuries in special transportation services by enhanced safety culture.

PubMed

Wretstrand, Anders; Petzäll, Jan; Bylund, Per-Olof; Falkmer, Torbjörn

2010-04-01

Previous research has pointed out that non-collision injuries occur among wheelchair users in Special Transportation Services (STS - a demand-responsive transport mode). The organization of such modes is also quite complex, involving both stakeholders and key personnel at different levels. Our objective was therefore to qualitatively explore the state of safety, as perceived and discussed within a workplace context. Focus groups were held with drivers of both taxi companies and bus companies. The results indicated that passengers run the risk of being injured without being involved in a vehicle collision. The pertinent organizational and corporate culture did not prioritize safety. The drivers identified some relatively clear-cut safety threats, primarily before and after a ride, at vehicle standstill. The driver's work place seemed to be surrounded with a reactive instead of proactive structure. We conclude that not only vehicle and wheelchair technical safety must be considered in STS, but also system safety. Instead of viewing drivers' error as a cause, it should be seen as a symptom of systems failure. Human error is connected to aspects of tools, tasks, and operating environment. Enhanced understanding and influence of these connections within STS and accessible public transport systems will promote safety for wheelchair users. Copyright 2009 IPEM. Published by Elsevier Ltd. All rights reserved.

Application of failure mode and effect analysis in an assisted reproduction technology laboratory.

PubMed

Intra, Giulia; Alteri, Alessandra; Corti, Laura; Rabellotti, Elisa; Papaleo, Enrico; Restelli, Liliana; Biondo, Stefania; Garancini, Maria Paola; Candiani, Massimo; Viganò, Paola

2016-08-01

Assisted reproduction technology laboratories have a very high degree of complexity. Mismatches of gametes or embryos can occur, with catastrophic consequences for patients. To minimize the risk of error, a multi-institutional working group applied failure mode and effects analysis (FMEA) to each critical activity/step as a method of risk assessment. This analysis led to the identification of the potential failure modes, together with their causes and effects, using the risk priority number (RPN) scoring system. In total, 11 individual steps and 68 different potential failure modes were identified. The highest ranked failure modes, with an RPN score of 25, encompassed 17 failures and pertained to "patient mismatch" and "biological sample mismatch". The maximum reduction in risk, with RPN reduced from 25 to 5, was mostly related to the introduction of witnessing. The critical failure modes in sample processing were improved by 50% in the RPN by focusing on staff training. Three indicators of FMEA success, based on technical skill, competence and traceability, have been evaluated after FMEA implementation. Witnessing by a second human operator should be introduced in the laboratory to avoid sample mix-ups. These findings confirm that FMEA can effectively reduce errors in assisted reproduction technology laboratories. Copyright © 2016 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

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.

Technical quality of root canal treatment performed by undergraduate students using hand instrumentation: a meta-analysis.

PubMed

Ribeiro, D M; Réus, J C; Felippe, W T; Pacheco-Pereira, C; Dutra, K L; Santos, J N; Porporatti, A L; De Luca Canto, G

2018-03-01

The technical quality of root canal treatment (RCT) may impact on the outcome. The quality of education received during undergraduate school may be linked to the quality of treatment provided in general dental practice. In this context, the aim of this systematic review was to answer the following focused questions: (i) What is the frequency of acceptable technical quality of root fillings, assessed radiographically, performed by undergraduate students? (ii) What are the most common errors assessed radiographically and reported in these treatments? For this purpose, articles that evaluated the quality of root fillings performed by undergraduate students were selected. Data were collected based on predetermined criteria. The key features from the included studies were extracted. GRADE-tool assessed the quality of the evidence. MAStARI evaluated the methodological quality, and a meta-analysis on all studies was conducted. At the end of the screening, 24 articles were identified. Overall frequency of acceptable technical quality of root fillings was 48%. From this total, 52% related to anterior teeth, 49% to premolars and 26% to molars. The main procedural errors reported were ledge formation, furcation perforation, apical transportation and apical perforation. The heterogeneity amongst the studies was high (84-99%). Five studies had a high risk of bias, eight had a moderate risk, and 11 had low risk. The overall quality of evidence identified was very low. The conclusion was that technical quality of root fillings performed by undergraduate students is low, which may reveal that endodontic education has limited achievement at undergraduate level. A plan to improve the quality of root fillings, and by extrapolation the overall quality of root canal treatment, should be discussed by the staff responsible for endodontic education and training. © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd.

Small cities face greater impact from automation.

PubMed

Frank, Morgan R; Sun, Lijun; Cebrian, Manuel; Youn, Hyejin; Rahwan, Iyad

2018-02-01

The city has proved to be the most successful form of human agglomeration and provides wide employment opportunities for its dwellers. As advances in robotics and artificial intelligence revive concerns about the impact of automation on jobs, a question looms: how will automation affect employment in cities? Here, we provide a comparative picture of the impact of automation across US urban areas. Small cities will undertake greater adjustments, such as worker displacement and job content substitutions. We demonstrate that large cities exhibit increased occupational and skill specialization due to increased abundance of managerial and technical professions. These occupations are not easily automatable, and, thus, reduce the potential impact of automation in large cities. Our results pass several robustness checks including potential errors in the estimation of occupational automation and subsampling of occupations. Our study provides the first empirical law connecting two societal forces: urban agglomeration and automation's impact on employment. © 2018 The Authors.

Parametric Modeling of the Safety Effects of NextGen Terminal Maneuvering Area Conflict Scenarios

NASA Technical Reports Server (NTRS)

Rogers, William H.; Waldron, Timothy P.; Stroiney, Steven R.

2011-01-01

The goal of this work was to analytically identify and quantify the issues, challenges, technical hurdles, and pilot-vehicle interface issues associated with conflict detection and resolution (CD&R)in emerging operational concepts for a NextGen terminal aneuvering area, including surface operations. To this end, the work entailed analytical and trade studies focused on modeling the achievable safety benefits of different CD&R strategies and concepts in the current and future airport environment. In addition, crew-vehicle interface and pilot performance enhancements and potential issues were analyzed based on review of envisioned NextGen operations, expected equipage advances, and human factors expertise. The results of perturbation analysis, which quantify the high-level performance impact of changes to key parameters such as median response time and surveillance position error, show that the analytical model developed could be useful in making technology investment decisions.

A new health system and its quality agenda.

PubMed

Detmer, D E

2001-01-01

This article reviews recent work on healthcare quality, highlights findings and recommendations of the Institute of Medicine (IOM) reports on medical errors and quality, and describes response to the reports to date. In it, Detmer, chair of the IOM's Board of Health Care Services and a member of its Committee on Quality of Health Care in America, identifies implications of the reports for healthcare delivery organizations and professionals and outlines ways organizations and professionals can improve the six dimensions of patient quality defined by the IOM. Sustained efforts at the point of care and in policy development are needed to overcome cultural inertia, realign incentives, support innovation, and address technical and human resource issues. Success requires that healthcare executives embrace the goal of transforming the healthcare sector into a true system and provide leadership for their organizations and communities in this most fundamental of challenges for twenty-first century healthcare.

Comparative Viral Metagenomics of Environmental Samples from Korea

PubMed Central

Kim, Min-Soo; Whon, Tae Woong

2013-01-01

The introduction of metagenomics into the field of virology has facilitated the exploration of viral communities in various natural habitats. Understanding the viral ecology of a variety of sample types throughout the biosphere is important per se, but it also has potential applications in clinical and diagnostic virology. However, the procedures used by viral metagenomics may produce technical errors, such as amplification bias, while public viral databases are very limited, which may hamper the determination of the viral diversity in samples. This review considers the current state of viral metagenomics, based on examples from Korean viral metagenomic studies-i.e., rice paddy soil, fermented foods, human gut, seawater, and the near-surface atmosphere. Viral metagenomics has become widespread due to various methodological developments, and much attention has been focused on studies that consider the intrinsic role of viruses that interact with their hosts. PMID:24124407

Small cities face greater impact from automation

PubMed Central

Sun, Lijun; Cebrian, Manuel; Rahwan, Iyad

2018-01-01

The city has proved to be the most successful form of human agglomeration and provides wide employment opportunities for its dwellers. As advances in robotics and artificial intelligence revive concerns about the impact of automation on jobs, a question looms: how will automation affect employment in cities? Here, we provide a comparative picture of the impact of automation across US urban areas. Small cities will undertake greater adjustments, such as worker displacement and job content substitutions. We demonstrate that large cities exhibit increased occupational and skill specialization due to increased abundance of managerial and technical professions. These occupations are not easily automatable, and, thus, reduce the potential impact of automation in large cities. Our results pass several robustness checks including potential errors in the estimation of occupational automation and subsampling of occupations. Our study provides the first empirical law connecting two societal forces: urban agglomeration and automation's impact on employment. PMID:29436514

From cognition to the system: developing a multilevel taxonomy of patient safety in general practice.

PubMed

Kostopoulou, O

The paper describes the process of developing a taxonomy of patient safety in general practice. The methodologies employed included fieldwork, task analysis and confidential reporting of patient-safety events in five West Midlands practices. Reported events were traced back to their root causes and contributing factors. The resulting taxonomy is based on a theoretical model of human cognition, includes multiple levels of classification to reflect the chain of causation and considers affective and physiological influences on performance. Events are classified at three levels. At level one, the information-processing model of cognition is used to classify errors. At level two, immediate causes are identified, internal and external to the individual. At level three, more remote causal factors are classified as either 'work organization' or 'technical' with subcategories. The properties of the taxonomy (validity, reliability, comprehensiveness) as well as its usability and acceptability remain to be tested with potential users.

Training situational awareness to reduce surgical errors in the operating room.

PubMed

Graafland, M; Schraagen, J M C; Boermeester, M A; Bemelman, W A; Schijven, M P

2015-01-01

Surgical errors result from faulty decision-making, misperceptions and the application of suboptimal problem-solving strategies, just as often as they result from technical failure. To date, surgical training curricula have focused mainly on the acquisition of technical skills. The aim of this review was to assess the validity of methods for improving situational awareness in the surgical theatre. A search was conducted in PubMed, Embase, the Cochrane Library and PsycINFO using predefined inclusion criteria, up to June 2014. All study types were considered eligible. The primary endpoint was validity for improving situational awareness in the surgical theatre at individual or team level. Nine articles were considered eligible. These evaluated surgical team crisis training in simulated environments for minimally invasive surgery (4) and open surgery (3), and training courses focused at training non-technical skills (2). Two studies showed that simulation-based surgical team crisis training has construct validity for assessing situational awareness in surgical trainees in minimally invasive surgery. None of the studies showed effectiveness of surgical crisis training on situational awareness in open surgery, whereas one showed face validity of a 2-day non-technical skills training course. To improve safety in the operating theatre, more attention to situational awareness is needed in surgical training. Few structured curricula have been developed and validation research remains limited. Strategies to improve situational awareness can be adopted from other industries. © 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.

Improved Quality in Aerospace Testing Through the Modern Design of Experiments

NASA Technical Reports Server (NTRS)

DeLoach, R.

2000-01-01

This paper illustrates how, in the presence of systematic error, the quality of an experimental result can be influenced by the order in which the independent variables are set. It is suggested that in typical experimental circumstances in which systematic errors are significant, the common practice of organizing the set point order of independent variables to maximize data acquisition rate results in a test matrix that fails to produce the highest quality research result. With some care to match the volume of data required to satisfy inference error risk tolerances, it is possible to accept a lower rate of data acquisition and still produce results of higher technical quality (lower experimental error) with less cost and in less time than conventional test procedures, simply by optimizing the sequence in which independent variable levels are set.

Impact of food and fluid intake on technical and biological measurement error in body composition assessment methods in athletes.

PubMed

Kerr, Ava; Slater, Gary J; Byrne, Nuala

2017-02-01

Two, three and four compartment (2C, 3C and 4C) models of body composition are popular methods to measure fat mass (FM) and fat-free mass (FFM) in athletes. However, the impact of food and fluid intake on measurement error has not been established. The purpose of this study was to evaluate standardised (overnight fasted, rested and hydrated) v. non-standardised (afternoon and non-fasted) presentation on technical and biological error on surface anthropometry (SA), 2C, 3C and 4C models. In thirty-two athletic males, measures of SA, dual-energy X-ray absorptiometry (DXA), bioelectrical impedance spectroscopy (BIS) and air displacement plethysmography (BOD POD) were taken to establish 2C, 3C and 4C models. Tests were conducted after an overnight fast (duplicate), about 7 h later after ad libitum food and fluid intake, and repeated 24 h later before and after ingestion of a specified meal. Magnitudes of changes in the mean and typical errors of measurement were determined. Mean change scores for non-standardised presentation and post meal tests for FM were substantially large in BIS, SA, 3C and 4C models. For FFM, mean change scores for non-standardised conditions produced large changes for BIS, 3C and 4C models, small for DXA, trivial for BOD POD and SA. Models that included a total body water (TBW) value from BIS (3C and 4C) were more sensitive to TBW changes in non-standardised conditions than 2C models. Biological error is minimised in all models with standardised presentation but DXA and BOD POD are acceptable if acute food and fluid intake remains below 500 g.

Technical note: 3D from standard digital photography of human crania-a preliminary assessment.

PubMed

Katz, David; Friess, Martin

2014-05-01

This study assessed three-dimensional (3D) photogrammetry as a tool for capturing and quantifying human skull morphology. While virtual reconstruction with 3D surface scanning technology has become an accepted part of the paleoanthropologist's tool kit, recent advances in 3D photogrammetry make it a potential alternative to dedicated surface scanners. The principal advantages of photogrammetry are more rapid raw data collection, simplicity and portability of setup, and reduced equipment costs. We tested the precision and repeatability of 3D photogrammetry by comparing digital models of human crania reconstructed from conventional, 2D digital photographs to those generated using a 3D surface scanner. Overall, the photogrammetry and scanner meshes showed low degrees of deviation from one another. Surface area estimates derived from photogrammetry models tended to be slightly larger. Landmark configurations generally did not cluster together based upon whether the reconstruction was created with photogrammetry or surface scanning technology. Average deviations of landmark coordinates recorded on photogrammetry models were within the generally allowable range of error in osteometry. Thus, while dependent upon the needs of the particular research project, 3D photogrammetry appears to be a suitable, lower-cost alternative to 3D imaging and scanning options. Copyright © 2014 Wiley Periodicals, Inc.

Simultaneous Control of Error Rates in fMRI Data Analysis

PubMed Central

Kang, Hakmook; Blume, Jeffrey; Ombao, Hernando; Badre, David

2015-01-01

The key idea of statistical hypothesis testing is to fix, and thereby control, the Type I error (false positive) rate across samples of any size. Multiple comparisons inflate the global (family-wise) Type I error rate and the traditional solution to maintaining control of the error rate is to increase the local (comparison-wise) Type II error (false negative) rates. However, in the analysis of human brain imaging data, the number of comparisons is so large that this solution breaks down: the local Type II error rate ends up being so large that scientifically meaningful analysis is precluded. Here we propose a novel solution to this problem: allow the Type I error rate to converge to zero along with the Type II error rate. It works because when the Type I error rate per comparison is very small, the accumulation (or global) Type I error rate is also small. This solution is achieved by employing the Likelihood paradigm, which uses likelihood ratios to measure the strength of evidence on a voxel-by-voxel basis. In this paper, we provide theoretical and empirical justification for a likelihood approach to the analysis of human brain imaging data. In addition, we present extensive simulations that show the likelihood approach is viable, leading to ‘cleaner’ looking brain maps and operationally superiority (lower average error rate). Finally, we include a case study on cognitive control related activation in the prefrontal cortex of the human brain. PMID:26272730

Human error and the search for blame

NASA Technical Reports Server (NTRS)

Denning, Peter J.

1989-01-01

Human error is a frequent topic in discussions about risks in using computer systems. A rational analysis of human error leads through the consideration of mistakes to standards that designers use to avoid mistakes that lead to known breakdowns. The irrational side, however, is more interesting. It conditions people to think that breakdowns are inherently wrong and that there is ultimately someone who is responsible. This leads to a search for someone to blame which diverts attention from: learning from the mistakes; seeing the limitations of current engineering methodology; and improving the discourse of design.

"Circadian cortical compensation": a longitudinal study of brain function during technical and cognitive skills in acutely sleep-deprived surgical residents.

PubMed

Leff, Daniel Richard; Orihuela-Espina, Felipe; Athanasiou, Thanos; Karimyan, Vahe; Elwell, Clare; Wong, John; Yang, Guang-Zhong; Darzi, Ara W

2010-12-01

To test the hypothesis that fatigue-induced performance decline in surgical residents is associated with changes in brain function as detected by functional near-infrared spectroscopy. Surgical residents (n = 7) participated in a prospective study involving 2-hourly objective measurements of neurocognitive skill (arithmetic calculations using Nintendo "brain training"), technical performance (surgical knot tying on a trainer, and monitoring time taken, path length and number of movements), and introspective fatigue (questionnaire-based) across 10 hours of acute sleep deprivation (10:00 PM to 8:00 PM. Simultaneously, changes in cortical oxyhemoglobin (HbO₂), deoxyhemoglobin (HHb), and total hemoglobin (HbT), inferring prefrontal function, were recorded by using functional near-infrared spectroscopy. Arithmetic performance remained stable despite increasing levels of subject fatigue (time: P = 0.07, errors: P = 0.70, efficiency: P = 0.58). Technical skill improved between the first (10:00 PM and the second (12:00 AM sessions (P < 0.05) and stabilized thereafter (12:00 AM to 8:00 AM. Greater activation was required to complete cognitive versus technical drills. Stimulus type (0: cognitive, 1: technical) was found to be an independent predictor of changes in cortical excitation (HbO₂: P < 0.01, HHb: P < 0.05, HbT: P < 0.01). Cortical responses to the cognitive task increased over the course of the simulated night shift. In addition, "time interval" was observed to be an independent predictor of cortical hemodynamic change (HbO₂: P < 0.01, HbT: P < 0.01). Neurocognitive tasks may tax the sleep-deprived resident more than well-learned technical skills. Performing cognitive skills at night, such as decision making, may depend upon enhanced prefrontal recruitment indicative of a focused attentional strategy and/or compensation to sleep deprivation. Further work should focus on determining whether errors in performance are associated with attentional lapses and failure of cortical compensation.

Genome engineering through CRISPR/Cas9 technology in the human germline and pluripotent stem cells.

PubMed

Vassena, R; Heindryckx, B; Peco, R; Pennings, G; Raya, A; Sermon, K; Veiga, A

2016-06-01

With the recent development of CRISPR (clustered regularly interspaced short palindromic repeats)/Cas9 genome editing technology, the possibility to genetically manipulate the human germline (gametes and embryos) has become a distinct technical possibility. Although many technical challenges still need to be overcome in order to achieve adequate efficiency and precision of the technology in human embryos, the path leading to genome editing has never been simpler, more affordable, and widespread. In this narrative review we seek to understand the possible impact of CRISR/Cas9 technology on human reproduction from the technical and ethical point of view, and suggest a course of action for the scientific community. This non-systematic review was carried out using Medline articles in English, as well as technical documents from the Human Fertilisation and Embryology Authority and reports in the media. The technical possibilities of the CRISPR/Cas9 technology with regard to human reproduction are analysed based on results obtained in model systems such as large animals and laboratory rodents. Further, the possibility of CRISPR/Cas9 use in the context of human reproduction, to modify embryos, germline cells, and pluripotent stem cells is reviewed based on the authors' expert opinion. Finally, the possible uses and consequences of CRISPR/cas9 gene editing in reproduction are analysed from the ethical point of view. We identify critical technical and ethical issues that should deter from employing CRISPR/Cas9 based technologies in human reproduction until they are clarified. Overcoming the numerous technical limitations currently associated with CRISPR/Cas9 mediated editing of the human germline will depend on intensive research that needs to be transparent and widely disseminated. Rather than a call to a generalized moratorium, or banning, of this type of research, efforts should be placed on establishing an open, international, collaborative and regulated research framework. Equally important, a societal discussion on the risks, benefits, and preferred applications of the new technology, including all relevant stakeholders, is urgently needed and should be promoted, and ultimately guide research priorities in this area. © The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

National Strategies for Developing Human Resources through Technical and Vocational Education and Training. The 2001 KRIVET International Conference on Technical and Vocational Education and Training [Proceedings] (Seoul, South Korea, November 21-23, 2001).

ERIC Educational Resources Information Center

Korea Research Inst. for Vocational Education and Training, Seoul.

This document contains 19 papers and case studies, in English and Korean, from a conference on national strategies for developing human resources through technical and vocational education and training. The following are representative: "The Need to Innovate and Optimize Resources [Keynote]" (Wataru Iwamoto); "School to Work…

CONCLUSIONS AND RECOMMENDATIONS OF THE EXPERT PANEL: TECHNICAL WORKSHOP ON HUMAN MILK SURVEILLANCE AND BIOMONITORING FOR ENVIRONMENTAL CHEMICALS IN THE UNITED STATES

EPA Science Inventory

The Technical Workshop focused on questions related to interpretation of information gathered from human milk biomonitoring studies. Biomonitoring can measure a person’s exposure to a chemical in his/her tissue. Human milk is a unique biological matrix for biomonitoring because i...

Why do adult dogs (Canis familiaris) commit the A-not-B search error?

PubMed

Sümegi, Zsófia; Kis, Anna; Miklósi, Ádám; Topál, József

2014-02-01

It has been recently reported that adult domestic dogs, like human infants, tend to commit perseverative search errors; that is, they select the previously rewarded empty location in Piagetian A-not-B search task because of the experimenter's ostensive communicative cues. There is, however, an ongoing debate over whether these findings reveal that dogs can use the human ostensive referential communication as a source of information or the phenomenon can be accounted for by "more simple" explanations like insufficient attention and learning based on local enhancement. In 2 experiments the authors systematically manipulated the type of human cueing (communicative or noncommunicative) adjacent to the A hiding place during both the A and B trials. Results highlight 3 important aspects of the dogs' A-not-B error: (a) search errors are influenced to a certain extent by dogs' motivation to retrieve the toy object; (b) human communicative and noncommunicative signals have different error-inducing effects; and (3) communicative signals presented at the A hiding place during the B trials but not during the A trials play a crucial role in inducing the A-not-B error and it can be induced even without demonstrating repeated hiding events at location A. These findings further confirm the notion that perseverative search error, at least partially, reflects a "ready-to-obey" attitude in the dog rather than insufficient attention and/or working memory.

Common medial frontal mechanisms of adaptive control in humans and rodents

PubMed Central

Frank, Michael J.; Laubach, Mark

2013-01-01

In this report, we describe how common brain networks within the medial frontal cortex facilitate adaptive behavioral control in rodents and humans. We demonstrate that low frequency oscillations below 12 Hz are dramatically modulated after errors in humans over mid-frontal cortex and in rats within prelimbic and anterior cingulate regions of medial frontal cortex. These oscillations were phase-locked between medial frontal cortex and motor areas in both rats and humans. In rats, single neurons that encoded prior behavioral outcomes were phase-coherent with low-frequency field oscillations particularly after errors. Inactivating medial frontal regions in rats led to impaired behavioral adjustments after errors, eliminated the differential expression of low frequency oscillations after errors, and increased low-frequency spike-field coupling within motor cortex. Our results describe a novel mechanism for behavioral adaptation via low-frequency oscillations and elucidate how medial frontal networks synchronize brain activity to guide performance. PMID:24141310

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

EPA Pesticide Factsheets

Background• Differing degrees of exposure error acrosspollutants• Previous focus on quantifying and accounting forexposure error in single-pollutant models• Examine exposure errors for multiple pollutantsand provide insights on the potential for bias andattenuation of effect estimates in single and bipollutantepidemiological models The National Exposure Research Laboratory (NERL) Human Exposure and Atmospheric Sciences Division (HEASD) conducts research in support of EPA mission to protect human health and the environment. HEASD research program supports Goal 1 (Clean Air) and Goal 4 (Healthy People) of EPA strategic plan. More specifically, our division conducts research to characterize the movement of pollutants from the source to contact with humans. Our multidisciplinary research program produces Methods, Measurements, and Models to identify relationships between and characterize processes that link source emissions, environmental concentrations, human exposures, and target-tissue dose. The impact of these tools is improved regulatory programs and policies for EPA.

44 CFR 152.9 - Reconsideration.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HOMELAND SECURITY FIRE PREVENTION AND CONTROL ASSISTANCE TO FIREFIGHTERS GRANT PROGRAM § 152.9... technical or procedural error in the processing of the application and can substantiate such assertions. As... experts, we cannot consider requests for reconsideration based upon the merits of an original application...

Maintaining data integrity in a rural clinical trial.

PubMed

Van den Broeck, Jan; Mackay, Melanie; Mpontshane, Nontobeko; Kany Kany Luabeya, Angelique; Chhagan, Meera; Bennish, Michael L

2007-01-01

Clinical trials conducted in rural resource-poor settings face special challenges in ensuring quality of data collection and handling. The variable nature of these challenges, ways to overcome them, and the resulting data quality are rarely reported in the literature. To provide a detailed example of establishing local data handling capacity for a clinical trial conducted in a rural area, highlight challenges and solutions in establishing such capacity, and to report the data quality obtained by the trial. We provide a descriptive case study of a data system for biological samples and questionnaire data, and the problems encountered during its implementation. To determine the quality of data we analyzed test-retest studies using Kappa statistics of inter- and intra-observer agreement on categorical data. We calculated Technical Errors of Measurement of anthropometric measurements, audit trail analysis was done to assess error correction rates, and residual error rates were calculated by database-to-source document comparison. Initial difficulties included the unavailability of experienced research nurses, programmers and data managers in this rural area and the difficulty of designing new software tools and a complex database while making them error-free. National and international collaboration and external monitoring helped ensure good data handling and implementation of good clinical practice. Data collection, fieldwork supervision and query handling depended on streamlined transport over large distances. The involvement of a community advisory board was helpful in addressing cultural issues and establishing community acceptability of data collection methods. Data accessibility for safety monitoring required special attention. Kappa values and Technical Errors of Measurement showed acceptable values. Residual error rates in key variables were low. The article describes the experience of a single-site trial and does not address challenges particular to multi-site trials. Obtaining and maintaining data integrity in rural clinical trials is feasible, can result in acceptable data quality and can be used to develop capacity in developing country sites. It does, however, involve special challenges and requirements.

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.

Selective DNA Pooling for Determination of Linkage between a Molecular Marker and a Quantitative Trait Locus

PubMed Central

Darvasi, A.; Soller, M.

1994-01-01

Selective genotyping is a method to reduce costs in marker-quantitative trait locus (QTL) linkage determination by genotyping only those individuals with extreme, and hence most informative, quantitative trait values. The DNA pooling strategy (termed: ``selective DNA pooling'') takes this one step further by pooling DNA from the selected individuals at each of the two phenotypic extremes, and basing the test for linkage on marker allele frequencies as estimated from the pooled samples only. This can reduce genotyping costs of marker-QTL linkage determination by up to two orders of magnitude. Theoretical analysis of selective DNA pooling shows that for experiments involving backcross, F(2) and half-sib designs, the power of selective DNA pooling for detecting genes with large effect, can be the same as that obtained by individual selective genotyping. Power for detecting genes with small effect, however, was found to decrease strongly with increase in the technical error of estimating allele frequencies in the pooled samples. The effect of technical error, however, can be markedly reduced by replication of technical procedures. It is also shown that a proportion selected of 0.1 at each tail will be appropriate for a wide range of experimental conditions. PMID:7896115

Using Model-Based Systems Engineering to Provide Artifacts for NASA Project Life-cycle and Technical Reviews

NASA Technical Reports Server (NTRS)

Parrott, Edith L.; Weiland, Karen J.

2017-01-01

This paper is for the AIAA Space Conference. The ability of systems engineers to use model-based systems engineering (MBSE) to generate self-consistent, up-to-date systems engineering products for project life-cycle and technical reviews is an important aspect for the continued and accelerated acceptance of MBSE. Currently, many review products are generated using labor-intensive, error-prone approaches based on documents, spreadsheets, and chart sets; a promised benefit of MBSE is that users will experience reductions in inconsistencies and errors. This work examines features of SysML that can be used to generate systems engineering products. Model elements, relationships, tables, and diagrams are identified for a large number of the typical systems engineering artifacts. A SysML system model can contain and generate most systems engineering products to a significant extent and this paper provides a guide on how to use MBSE to generate products for project life-cycle and technical reviews. The use of MBSE can reduce the schedule impact usually experienced for review preparation, as in many cases the review products can be auto-generated directly from the system model. These approaches are useful to systems engineers, project managers, review board members, and other key project stakeholders.

Cutting the Cord: Discrimination and Command Responsibility in Autonomous Lethal Weapons

DTIC Science & Technology

2014-02-13

machine responses to identical stimuli, and it was the job of a third party human “witness” to determine which participant was man and which was...machines may be error free, but there are potential benefits to be gained through autonomy if machines can meet or exceed human performance in...lieu of human operators and reap the benefits that autonomy provides. Human and Machine Error It would be foolish to assert that either humans

75 FR 48743 - Mandatory Reporting of Greenhouse Gases

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-11

...EPA is proposing to amend specific provisions in the GHG reporting rule to clarify certain provisions, to correct technical and editorial errors, and to address certain questions and issues that have arisen since promulgation. These proposed changes include providing additional information and clarity on existing requirements, allowing greater flexibility or simplified calculation methods for certain sources in a facility, amending data reporting requirements to provide additional clarity on when different types of GHG emissions need to be calculated and reported, clarifying terms and definitions in certain equations, and technical corrections.

75 FR 79091 - Mandatory Reporting of Greenhouse Gases

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-17

...EPA is amending specific provisions in the greenhouse gas reporting rule to clarify certain provisions, to correct technical and editorial errors, and to address certain questions and issues that have arisen since promulgation. These final changes include generally providing additional information and clarity on existing requirements, allowing greater flexibility or simplified calculation methods for certain sources, amending data reporting requirements to provide additional clarity on when different types of greenhouse gas emissions need to be calculated and reported, clarifying terms and definitions in certain equations and other technical corrections and amendments.

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

PubMed

Al-Hakim, Latif; Sevdalis, Nick; Maiping, Tanaphon; Watanachote, Damrongpan; Sengupta, Shomik; Dissaranan, Charuspong

2015-09-01

This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

A Method for Oscillation Errors Restriction of SINS Based on Forecasted Time Series.

PubMed

Zhao, Lin; Li, Jiushun; Cheng, Jianhua; Jia, Chun; Wang, Qiufan

2015-07-17

Continuity, real-time, and accuracy are the key technical indexes of evaluating comprehensive performance of a strapdown inertial navigation system (SINS). However, Schuler, Foucault, and Earth periodic oscillation errors significantly cut down the real-time accuracy of SINS. A method for oscillation error restriction of SINS based on forecasted time series is proposed by analyzing the characteristics of periodic oscillation errors. The innovative method gains multiple sets of navigation solutions with different phase delays in virtue of the forecasted time series acquired through the measurement data of the inertial measurement unit (IMU). With the help of curve-fitting based on least square method, the forecasted time series is obtained while distinguishing and removing small angular motion interference in the process of initial alignment. Finally, the periodic oscillation errors are restricted on account of the principle of eliminating the periodic oscillation signal with a half-wave delay by mean value. Simulation and test results show that the method has good performance in restricting the Schuler, Foucault, and Earth oscillation errors of SINS.

A Method for Oscillation Errors Restriction of SINS Based on Forecasted Time Series

PubMed Central

Zhao, Lin; Li, Jiushun; Cheng, Jianhua; Jia, Chun; Wang, Qiufan

2015-01-01

Continuity, real-time, and accuracy are the key technical indexes of evaluating comprehensive performance of a strapdown inertial navigation system (SINS). However, Schuler, Foucault, and Earth periodic oscillation errors significantly cut down the real-time accuracy of SINS. A method for oscillation error restriction of SINS based on forecasted time series is proposed by analyzing the characteristics of periodic oscillation errors. The innovative method gains multiple sets of navigation solutions with different phase delays in virtue of the forecasted time series acquired through the measurement data of the inertial measurement unit (IMU). With the help of curve-fitting based on least square method, the forecasted time series is obtained while distinguishing and removing small angular motion interference in the process of initial alignment. Finally, the periodic oscillation errors are restricted on account of the principle of eliminating the periodic oscillation signal with a half-wave delay by mean value. Simulation and test results show that the method has good performance in restricting the Schuler, Foucault, and Earth oscillation errors of SINS. PMID:26193283

Managing human error in aviation.

PubMed

Helmreich, R L

1997-05-01

Crew resource management (CRM) programs were developed to address team and leadership aspects of piloting modern airplanes. The goal is to reduce errors through team work. Human factors research and social, cognitive, and organizational psychology are used to develop programs tailored for individual airlines. Flight crews study accident case histories, group dynamics, and human error. Simulators provide pilots with the opportunity to solve complex flight problems. CRM in the simulator is called line-oriented flight training (LOFT). In automated cockpits CRM promotes the idea of automation as a crew member. Cultural aspects of aviation include professional, business, and national culture. The aviation CRM model has been adapted for training surgeons and operating room staff in human factors.

The Experimental Probe of Inflationary Cosmology: A Mission Concept Study for NASA's Einstein Inflation Probe

NASA Technical Reports Server (NTRS)

2008-01-01

When we began our study we sought to answer five fundamental implementation questions: 1) can foregrounds be measured and subtracted to a sufficiently low level?; 2) can systematic errors be controlled?; 3) can we develop optics with sufficiently large throughput, low polarization, and frequency coverage from 30 to 300 GHz?; 4) is there a technical path to realizing the sensitivity and systematic error requirements?; and 5) what are the specific mission architecture parameters, including cost? Detailed answers to these questions are contained in this report.

Center for Seismic Studies Final Technical Report, October 1992 through October 1993

DTIC Science & Technology

1994-02-07

SECURITY CLASSIFICATION 18. SECURITY CLASSIFICATION 19. SECURITY CLASSIFICATION 20. LIMITATION OF ABSTRACT OF REPORT OF THIS PAGE OF ABSTRACT...Upper limit of depth error as a function of mb for estimates based on P and S waves for three netowrks : GSETr-2, ALPHA, and ALPHA + a 50 station...U 4A 4 U 4S as 1 I I I Figure 42: Upper limit of depth error as a function of mb for estimatesbased on P and S waves for three netowrk : GSETT-2o ALPHA

Empirical Analysis of Systematic Communication Errors.

DTIC Science & Technology

1981-09-01

human o~ . .... 8 components in communication systems. (Systematic errors were defined to be those that occur regularly in human communication links...phase of the human communication process and focuses on the linkage between a specific piece of information (and the receiver) and the transmission...communication flow. (2) Exchange. Exchange is the next phase in human communication and entails a concerted effort on the part of the sender and receiver to share

HRA Aerospace Challenges

NASA Technical Reports Server (NTRS)

DeMott, Diana

2013-01-01

Compared to equipment designed to perform the same function over and over, humans are just not as reliable. Computers and machines perform the same action in the same way repeatedly getting the same result, unless equipment fails or a human interferes. Humans who are supposed to perform the same actions repeatedly often perform them incorrectly due to a variety of issues including: stress, fatigue, illness, lack of training, distraction, acting at the wrong time, not acting when they should, not following procedures, misinterpreting information or inattention to detail. Why not use robots and automatic controls exclusively if human error is so common? In an emergency or off normal situation that the computer, robotic element, or automatic control system is not designed to respond to, the result is failure unless a human can intervene. The human in the loop may be more likely to cause an error, but is also more likely to catch the error and correct it. When it comes to unexpected situations, or performing multiple tasks outside the defined mission parameters, humans are the only viable alternative. Human Reliability Assessments (HRA) identifies ways to improve human performance and reliability and can lead to improvements in systems designed to interact with humans. Understanding the context of the situation that can lead to human errors, which include taking the wrong action, no action or making bad decisions provides additional information to mitigate risks. With improved human reliability comes reduced risk for the overall operation or project.

Identifying Human Factors Issues in Aircraft Maintenance Operations

NASA Technical Reports Server (NTRS)

Veinott, Elizabeth S.; Kanki, Barbara G.; Shafto, Michael G. (Technical Monitor)

1995-01-01

Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.

Managing Errors to Reduce Accidents in High Consequence Networked Information Systems

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

Ganter, J.H.

1999-02-01

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

Missing data and technical variability in single-cell RNA-sequencing experiments.

PubMed

Hicks, Stephanie C; Townes, F William; Teng, Mingxiang; Irizarry, Rafael A

2017-11-06

Until recently, high-throughput gene expression technology, such as RNA-Sequencing (RNA-seq) required hundreds of thousands of cells to produce reliable measurements. Recent technical advances permit genome-wide gene expression measurement at the single-cell level. Single-cell RNA-Seq (scRNA-seq) is the most widely used and numerous publications are based on data produced with this technology. However, RNA-seq and scRNA-seq data are markedly different. In particular, unlike RNA-seq, the majority of reported expression levels in scRNA-seq are zeros, which could be either biologically-driven, genes not expressing RNA at the time of measurement, or technically-driven, genes expressing RNA, but not at a sufficient level to be detected by sequencing technology. Another difference is that the proportion of genes reporting the expression level to be zero varies substantially across single cells compared to RNA-seq samples. However, it remains unclear to what extent this cell-to-cell variation is being driven by technical rather than biological variation. Furthermore, while systematic errors, including batch effects, have been widely reported as a major challenge in high-throughput technologies, these issues have received minimal attention in published studies based on scRNA-seq technology. Here, we use an assessment experiment to examine data from published studies and demonstrate that systematic errors can explain a substantial percentage of observed cell-to-cell expression variability. Specifically, we present evidence that some of these reported zeros are driven by technical variation by demonstrating that scRNA-seq produces more zeros than expected and that this bias is greater for lower expressed genes. In addition, this missing data problem is exacerbated by the fact that this technical variation varies cell-to-cell. Then, we show how this technical cell-to-cell variability can be confused with novel biological results. Finally, we demonstrate and discuss how batch-effects and confounded experiments can intensify the problem. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Investigating mode errors on automated flight decks: illustrating the problem-driven, cumulative, and interdisciplinary nature of human factors research.

PubMed

Sarter, Nadine

2008-06-01

The goal of this article is to illustrate the problem-driven, cumulative, and highly interdisciplinary nature of human factors research by providing a brief overview of the work on mode errors on modern flight decks over the past two decades. Mode errors on modem flight decks were first reported in the late 1980s. Poor feedback, inadequate mental models of the automation, and the high degree of coupling and complexity of flight deck systems were identified as main contributors to these breakdowns in human-automation interaction. Various improvements of design, training, and procedures were proposed to address these issues. The author describes when and why the problem of mode errors surfaced, summarizes complementary research activities that helped identify and understand the contributing factors to mode errors, and describes some countermeasures that have been developed in recent years. This brief review illustrates how one particular human factors problem in the aviation domain enabled various disciplines and methodological approaches to contribute to a better understanding of, as well as provide better support for, effective human-automation coordination. Converging operations and interdisciplinary collaboration over an extended period of time are hallmarks of successful human factors research. The reported body of research can serve as a model for future research and as a teaching tool for students in this field of work.

The Swiss cheese model of adverse event occurrence--Closing the holes.

PubMed

Stein, James E; Heiss, Kurt

2015-12-01

Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability. Copyright © 2015 Elsevier Inc. All rights reserved.

Behind Human Error: Cognitive Systems, Computers and Hindsight

DTIC Science & Technology

1994-12-01

evaluations • Organize and/or conduct workshops and conferences CSERIAC is a Department of Defense Information Analysis Cen- ter sponsored by the Defense...Process 185 Neutral Observer Criteria 191 Error Analysis as Causal Judgment 193 Error as Information 195 A Fundamental Surprise 195 What is Human...Kahnemann, 1974), and in risk analysis (Dougherty and Fragola, 1990). The discussions have continued in a wide variety of forums, includ- ing the

Monte Carlo simulation of expert judgments on human errors in chemical analysis--a case study of ICP-MS.

PubMed

Kuselman, Ilya; Pennecchi, Francesca; Epstein, Malka; Fajgelj, Ales; Ellison, Stephen L R

2014-12-01

Monte Carlo simulation of expert judgments on human errors in a chemical analysis was used for determination of distributions of the error quantification scores (scores of likelihood and severity, and scores of effectiveness of a laboratory quality system in prevention of the errors). The simulation was based on modeling of an expert behavior: confident, reasonably doubting and irresolute expert judgments were taken into account by means of different probability mass functions (pmfs). As a case study, 36 scenarios of human errors which may occur in elemental analysis of geological samples by ICP-MS were examined. Characteristics of the score distributions for three pmfs of an expert behavior were compared. Variability of the scores, as standard deviation of the simulated score values from the distribution mean, was used for assessment of the score robustness. A range of the score values, calculated directly from elicited data and simulated by a Monte Carlo method for different pmfs, was also discussed from the robustness point of view. It was shown that robustness of the scores, obtained in the case study, can be assessed as satisfactory for the quality risk management and improvement of a laboratory quality system against human errors. Copyright © 2014 Elsevier B.V. All rights reserved.

Cross-Cultural HRD. Symposium.

ERIC Educational Resources Information Center

2002

The first of three papers from this symposium on cross-cultural human resource development (HRD), "Determinants of Supply of Technical Training Opportunities for Human Capital Development in Kenya" (Moses Waithanji Ngware, Fredrick Muyia Nafukho) reports findings from interviews of technical training institute department heads in Kenya…

Hazardous Waste Management System - Identification and Listing of Hazardous Waste - Recycled Used Oil Management Standards - Federal Register Notice, May 3, 1993

EPA Pesticide Factsheets

This action corrects several technical errors and provides clarifying amendments to the final recycled used oil management standards rule. The final rule was published on September 10, 1992 (57 FR 41566).

Meta-Evaluation

ERIC Educational Resources Information Center

Stufflebeam, Daniel L.

2011-01-01

Good evaluation requires that evaluation efforts themselves be evaluated. Many things can and often do go wrong in evaluation work. Accordingly, it is necessary to check evaluations for problems such as bias, technical error, administrative difficulties, and misuse. Such checks are needed both to improve ongoing evaluation activities and to assess…

Technical note: Bayesian calibration of dynamic ruminant nutrition models.

PubMed

Reed, K F; Arhonditsis, G B; France, J; Kebreab, E

2016-08-01

Mechanistic models of ruminant digestion and metabolism have advanced our understanding of the processes underlying ruminant animal physiology. Deterministic modeling practices ignore the inherent variation within and among individual animals and thus have no way to assess how sources of error influence model outputs. We introduce Bayesian calibration of mathematical models to address the need for robust mechanistic modeling tools that can accommodate error analysis by remaining within the bounds of data-based parameter estimation. For the purpose of prediction, the Bayesian approach generates a posterior predictive distribution that represents the current estimate of the value of the response variable, taking into account both the uncertainty about the parameters and model residual variability. Predictions are expressed as probability distributions, thereby conveying significantly more information than point estimates in regard to uncertainty. Our study illustrates some of the technical advantages of Bayesian calibration and discusses the future perspectives in the context of animal nutrition modeling. Copyright © 2016 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.

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

PubMed

Kluge, Annette; Grauel, Britta; Burkolter, Dina

2013-03-01

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

Human-computer interaction in multitask situations

NASA Technical Reports Server (NTRS)

Rouse, W. B.

1977-01-01

Human-computer interaction in multitask decisionmaking situations is considered, and it is proposed that humans and computers have overlapping responsibilities. Queueing theory is employed to model this dynamic approach to the allocation of responsibility between human and computer. Results of simulation experiments are used to illustrate the effects of several system variables including number of tasks, mean time between arrivals of action-evoking events, human-computer speed mismatch, probability of computer error, probability of human error, and the level of feedback between human and computer. Current experimental efforts are discussed and the practical issues involved in designing human-computer systems for multitask situations are considered.

Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: a prospective randomized controlled study.

PubMed

Lendvay, Thomas S; Brand, Timothy C; White, Lee; Kowalewski, Timothy; Jonnadula, Saikiran; Mercer, Laina D; Khorsand, Derek; Andros, Justin; Hannaford, Blake; Satava, Richard M

2013-06-01

Preoperative simulation warm-up has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized that a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors. In a 2-center randomized trial, 51 residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot (Intuitive Surgical Inc). Once they successfully achieved performance benchmarks, surgeons were randomized to either receive a 3- to 5-minute VR simulator warm-up or read a leisure book for 10 minutes before performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical, and cognitive errors. Task time (-29.29 seconds, p = 0.001; 95% CI, -47.03 to -11.56), path length (-79.87 mm; p = 0.014; 95% CI, -144.48 to -15.25), and cognitive errors were reduced in the warm-up group compared with the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32; p = 0.020; 95% CI, 0.06-0.59) were reduced after the dissimilar VR task. When surgeons were stratified by earlier robotic and laparoscopic clinical experience, the more experienced surgeons (n = 17) demonstrated significant improvements from warm-up in task time (-53.5 seconds; p = 0.001; 95% CI, -83.9 to -23.0) and economy of motion (0.63 mm/s; p = 0.007; 95% CI, 0.18-1.09), and improvement in these metrics was not statistically significantly appreciated in the less-experienced cohort (n = 34). We observed significant performance improvement and error reduction rates among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing), suggesting the generalizability of the warm-up. Copyright © 2013 American College of Surgeons. All rights reserved.

Virtual Reality Robotic Surgery Warm-Up Improves Task Performance in a Dry Lab Environment: A Prospective Randomized Controlled Study

PubMed Central

Lendvay, Thomas S.; Brand, Timothy C.; White, Lee; Kowalewski, Timothy; Jonnadula, Saikiran; Mercer, Laina; Khorsand, Derek; Andros, Justin; Hannaford, Blake; Satava, Richard M.

2014-01-01

Background Pre-operative simulation “warm-up” has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors. Study Design In a two-center randomized trial, fifty-one residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot. Once successfully achieving performance benchmarks, surgeons were randomized to either receive a 3-5 minute VR simulator warm-up or read a leisure book for 10 minutes prior to performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical and cognitive errors. Results Task time (-29.29sec, p=0.001, 95%CI-47.03,-11.56), path length (-79.87mm, p=0.014, 95%CI -144.48,-15.25), and cognitive errors were reduced in the warm-up group compared to the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32, p=0.020, 95%CI 0.06,0.59) were reduced after the dissimilar VR task. When surgeons were stratified by prior robotic and laparoscopic clinical experience, the more experienced surgeons(n=17) demonstrated significant improvements from warm-up in task time (-53.5sec, p=0.001, 95%CI -83.9,-23.0) and economy of motion (0.63mm/sec, p=0.007, 95%CI 0.18,1.09), whereas improvement in these metrics was not statistically significantly appreciated in the less experienced cohort(n=34). Conclusions We observed a significant performance improvement and error reduction rate among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing) suggesting the generalizability of the warm-up. PMID:23583618

Use of units of measurement error in anthropometric comparisons.

PubMed

Lucas, Teghan; Henneberg, Maciej

2017-09-01

Anthropometrists attempt to minimise measurement errors, however, errors cannot be eliminated entirely. Currently, measurement errors are simply reported. Measurement errors should be included into analyses of anthropometric data. This study proposes a method which incorporates measurement errors into reported values, replacing metric units with 'units of technical error of measurement (TEM)' by applying these to forensics, industrial anthropometry and biological variation. The USA armed forces anthropometric survey (ANSUR) contains 132 anthropometric dimensions of 3982 individuals. Concepts of duplication and Euclidean distance calculations were applied to the forensic-style identification of individuals in this survey. The National Size and Shape Survey of Australia contains 65 anthropometric measurements of 1265 women. This sample was used to show how a woman's body measurements expressed in TEM could be 'matched' to standard clothing sizes. Euclidean distances show that two sets of repeated anthropometric measurements of the same person cannot be matched (> 0) on measurements expressed in millimetres but can in units of TEM (= 0). Only 81 women can fit into any standard clothing size when matched using centimetres, with units of TEM, 1944 women fit. The proposed method can be applied to all fields that use anthropometry. Units of TEM are considered a more reliable unit of measurement for comparisons.

Direct Geolocation of TerraSAR-X Spotlight Mode Image and Error Correction

NASA Astrophysics Data System (ADS)

Zhou, Xiao; Zeng, Qiming; Jiao, Jian; Zhang, Jingfa; Gong, Lixia

2013-01-01

The GERMAN TerraSAR-X mission was launched in June 2007, operating a versatile new-generation SAR sensor in X-band. Its Spotlight mode providing SAR images at very high resolution of about 1m. The product’s specified 3-D geolocation accuracy is tightened to 1m according to the official technical report. However, this accuracy is able to be achieved relies on not only robust mathematical basis of SAR geolocation, but also well knowledge of error sources and their correction. The research focuses on geolocation of TerraSAR-X spotlight image. Mathematical model and resolving algorithms have been analyzed. Several error sources have been researched and corrected especially. The effectiveness and accuracy of the research was verified by the experiment results.

Solutions to decrease a systematic error related to AAPH addition in the fluorescence-based ORAC assay.

PubMed

Mellado-Ortega, Elena; Zabalgogeazcoa, Iñigo; Vázquez de Aldana, Beatriz R; Arellano, Juan B

2017-02-15

Oxygen radical absorbance capacity (ORAC) assay in 96-well multi-detection plate readers is a rapid method to determine total antioxidant capacity (TAC) in biological samples. A disadvantage of this method is that the antioxidant inhibition reaction does not start in all of the 96 wells at the same time due to technical limitations when dispensing the free radical-generating azo initiator 2,2'-azobis (2-methyl-propanimidamide) dihydrochloride (AAPH). The time delay between wells yields a systematic error that causes statistically significant differences in TAC determination of antioxidant solutions depending on their plate position. We propose two alternative solutions to avoid this AAPH-dependent error in ORAC assays. Copyright © 2016 Elsevier Inc. All rights reserved.

Combining task analysis and fault tree analysis for accident and incident analysis: a case study from Bulgaria.

PubMed

Doytchev, Doytchin E; Szwillus, Gerd

2009-11-01

Understanding the reasons for incident and accident occurrence is important for an organization's safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose an analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). The former method identifies the root causes of an accident/incident, while the latter analyses the way people perform the tasks in their work environment and how they interact with machines or colleagues. These methods were complemented with the use of the Human Error Identification in System Tools (HEIST) methodology and the concept of Performance Shaping Factors (PSF) to deepen the insight into the error modes of an operator's behaviour. HEIST shows the external error modes that caused the human error and the factors that prompted the human to err. To show the validity of the approach, a case study at a Bulgarian Hydro power plant was carried out. An incident - the flooding of the plant's basement - was analysed by combining the afore-mentioned methods. The case study shows that Task Analysis in combination with other methods can be applied successfully to human error analysis, revealing details about erroneous actions in a realistic situation.

Object permanence in adult common marmosets (Callithrix jacchus): not everything is an "A-not-B" error that seems to be one.

PubMed

Kis, Anna; Gácsi, Márta; Range, Friederike; Virányi, Zsófia

2012-01-01

In this paper, we describe a behaviour pattern similar to the "A-not-B" error found in human infants and young apes in a monkey species, the common marmosets (Callithrix jacchus). In contrast to the classical explanation, recently it has been suggested that the "A-not-B" error committed by human infants is at least partially due to misinterpretation of the hider's ostensively communicated object hiding actions as potential 'teaching' demonstrations during the A trials. We tested whether this so-called Natural Pedagogy hypothesis would account for the A-not-B error that marmosets commit in a standard object permanence task, but found no support for the hypothesis in this species. Alternatively, we present evidence that lower level mechanisms, such as attention and motivation, play an important role in committing the "A-not-B" error in marmosets. We argue that these simple mechanisms might contribute to the effect of undeveloped object representational skills in other species including young non-human primates that commit the A-not-B error.

First-order error budgeting for LUVOIR mission

NASA Astrophysics Data System (ADS)

Lightsey, Paul A.; Knight, J. Scott; Feinberg, Lee D.; Bolcar, Matthew R.; Shaklan, Stuart B.

2017-09-01

Future large astronomical telescopes in space will have architectures that will have complex and demanding requirements to meet the science goals. The Large UV/Optical/IR Surveyor (LUVOIR) mission concept being assessed by the NASA/Goddard Space Flight Center is expected to be 9 to 15 meters in diameter, have a segmented primary mirror and be diffraction limited at a wavelength of 500 nanometers. The optical stability is expected to be in the picometer range for minutes to hours. Architecture studies to support the NASA Science and Technology Definition teams (STDTs) are underway to evaluate systems performance improvements to meet the science goals. To help define the technology needs and assess performance, a first order error budget has been developed. Like the JWST error budget, the error budget includes the active, adaptive and passive elements in spatial and temporal domains. JWST performance is scaled using first order approximations where appropriate and includes technical advances in telescope control.

Verification of image orthorectification techniques for low-cost geometric inspection of masonry arch bridges

NASA Astrophysics Data System (ADS)

González-Jorge, Higinio; Riveiro, Belén; Varela, María; Arias, Pedro

2012-07-01

A low-cost image orthorectification tool based on the utilization of compact cameras and scale bars is developed to obtain the main geometric parameters of masonry bridges for inventory and routine inspection purposes. The technique is validated in three different bridges by comparison with laser scanning data. The surveying process is very delicate and must make a balance between working distance and angle. Three different cameras are used in the study to establish the relationship between the error and the camera model. Results depict nondependence in error between the length of the bridge element, the type of bridge, and the type of element. Error values for all the cameras are below 4 percent (95 percent of the data). A compact Canon camera, the model with the best technical specifications, shows an error level ranging from 0.5 to 1.5 percent.

Updating expected action outcome in the medial frontal cortex involves an evaluation of error type.

PubMed

Maier, Martin E; Steinhauser, Marco

2013-10-02

Forming expectations about the outcome of an action is an important prerequisite for action control and reinforcement learning in the human brain. The medial frontal cortex (MFC) has been shown to play an important role in the representation of outcome expectations, particularly when an update of expected outcome becomes necessary because an error is detected. However, error detection alone is not always sufficient to compute expected outcome because errors can occur in various ways and different types of errors may be associated with different outcomes. In the present study, we therefore investigate whether updating expected outcome in the human MFC is based on an evaluation of error type. Our approach was to consider an electrophysiological correlate of MFC activity on errors, the error-related negativity (Ne/ERN), in a task in which two types of errors could occur. Because the two error types were associated with different amounts of monetary loss, updating expected outcomes on error trials required an evaluation of error type. Our data revealed a pattern of Ne/ERN amplitudes that closely mirrored the amount of monetary loss associated with each error type, suggesting that outcome expectations are updated based on an evaluation of error type. We propose that this is achieved by a proactive evaluation process that anticipates error types by continuously monitoring error sources or by dynamically representing possible response-outcome relations.

45 CFR 1168.205 - Professional and technical services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 3 2011-10-01 2011-10-01 false Professional and technical services. 1168.205 Section 1168.205 Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL FOUNDATION ON THE ARTS AND THE HUMANITIES NATIONAL ENDOWMENT FOR THE HUMANITIES NEW RESTRICTIONS ON LOBBYING...

45 CFR 1168.300 - Professional and technical services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 3 2011-10-01 2011-10-01 false Professional and technical services. 1168.300 Section 1168.300 Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL FOUNDATION ON THE ARTS AND THE HUMANITIES NATIONAL ENDOWMENT FOR THE HUMANITIES NEW RESTRICTIONS ON LOBBYING...

45 CFR 1168.300 - Professional and technical services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 45 Public Welfare 3 2010-10-01 2010-10-01 false Professional and technical services. 1168.300 Section 1168.300 Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL FOUNDATION ON THE ARTS AND THE HUMANITIES NATIONAL ENDOWMENT FOR THE HUMANITIES NEW RESTRICTIONS ON LOBBYING...

45 CFR 1168.205 - Professional and technical services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 45 Public Welfare 3 2010-10-01 2010-10-01 false Professional and technical services. 1168.205 Section 1168.205 Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL FOUNDATION ON THE ARTS AND THE HUMANITIES NATIONAL ENDOWMENT FOR THE HUMANITIES NEW RESTRICTIONS ON LOBBYING...

Theoretical Perspectives on Fishing Vessel Accidents and Their Prevention.

ERIC Educational Resources Information Center

Boshier, Roger

Fishing vessel accidents occur because of complex interactions of human, technical, and environmental factors. Although they usually occur because of human actions, thoughts, or behavior, investigators and prevention educators are preoccupied with technical matters and equipment. Equipment, machinery, weather, and other objective facts are…

Accounting for measurement error in human life history trade-offs using structural equation modeling.

PubMed

Helle, Samuli

2018-03-01

Revealing causal effects from correlative data is very challenging and a contemporary problem in human life history research owing to the lack of experimental approach. Problems with causal inference arising from measurement error in independent variables, whether related either to inaccurate measurement technique or validity of measurements, seem not well-known in this field. The aim of this study is to show how structural equation modeling (SEM) with latent variables can be applied to account for measurement error in independent variables when the researcher has recorded several indicators of a hypothesized latent construct. As a simple example of this approach, measurement error in lifetime allocation of resources to reproduction in Finnish preindustrial women is modelled in the context of the survival cost of reproduction. In humans, lifetime energetic resources allocated in reproduction are almost impossible to quantify with precision and, thus, typically used measures of lifetime reproductive effort (e.g., lifetime reproductive success and parity) are likely to be plagued by measurement error. These results are contrasted with those obtained from a traditional regression approach where the single best proxy of lifetime reproductive effort available in the data is used for inference. As expected, the inability to account for measurement error in women's lifetime reproductive effort resulted in the underestimation of its underlying effect size on post-reproductive survival. This article emphasizes the advantages that the SEM framework can provide in handling measurement error via multiple-indicator latent variables in human life history studies. © 2017 Wiley Periodicals, Inc.

Reliability of drivers in urban intersections.

PubMed

Gstalter, Herbert; Fastenmeier, Wolfgang

2010-01-01

The concept of human reliability has been widely used in industrial settings by human factors experts to optimise the person-task fit. Reliability is estimated by the probability that a task will successfully be completed by personnel in a given stage of system operation. Human Reliability Analysis (HRA) is a technique used to calculate human error probabilities as the ratio of errors committed to the number of opportunities for that error. To transfer this notion to the measurement of car driver reliability the following components are necessary: a taxonomy of driving tasks, a definition of correct behaviour in each of these tasks, a list of errors as deviations from the correct actions and an adequate observation method to register errors and opportunities for these errors. Use of the SAFE-task analysis procedure recently made it possible to derive driver errors directly from the normative analysis of behavioural requirements. Driver reliability estimates could be used to compare groups of tasks (e.g. different types of intersections with their respective regulations) as well as groups of drivers' or individual drivers' aptitudes. This approach was tested in a field study with 62 drivers of different age groups. The subjects drove an instrumented car and had to complete an urban test route, the main features of which were 18 intersections representing six different driving tasks. The subjects were accompanied by two trained observers who recorded driver errors using standardized observation sheets. Results indicate that error indices often vary between both the age group of drivers and the type of driving task. The highest error indices occurred in the non-signalised intersection tasks and the roundabout, which exactly equals the corresponding ratings of task complexity from the SAFE analysis. A comparison of age groups clearly shows the disadvantage of older drivers, whose error indices in nearly all tasks are significantly higher than those of the other groups. The vast majority of these errors could be explained by high task load in the intersections, as they represent difficult tasks. The discussion shows how reliability estimates can be used in a constructive way to propose changes in car design, intersection layout and regulation as well as driver training.

Global Proteomic Analysis of Human Liver Microsomes: Rapid Characterization and Quantification of Hepatic Drug-Metabolizing Enzymes.

PubMed

Achour, Brahim; Al Feteisi, Hajar; Lanucara, Francesco; Rostami-Hodjegan, Amin; Barber, Jill

2017-06-01

Many genetic and environmental factors lead to interindividual variations in the metabolism and transport of drugs, profoundly affecting efficacy and toxicity. Precision dosing, that is, targeting drug dose to a well characterized subpopulation, is dependent on quantitative models of the profiles of drug-metabolizing enzymes (DMEs) and transporters within that subpopulation, informed by quantitative proteomics. We report the first use of ion mobility-mass spectrometry for this purpose, allowing rapid, robust, label-free quantification of human liver microsomal (HLM) proteins from distinct individuals. Approximately 1000 proteins were identified and quantified in four samples, including an average of 70 DMEs. Technical and biological variabilities were distinguishable, with technical variability accounting for about 10% of total variability. The biological variation between patients was clearly identified, with samples showing a range of expression profiles for cytochrome P450 and uridine 5'-diphosphoglucuronosyltransferase enzymes. Our results showed excellent agreement with previous data from targeted methods. The label-free method, however, allowed a fuller characterization of the in vitro system, showing, for the first time, that HLMs are significantly heterogeneous. Further, the traditional units of measurement of DMEs (pmol mg -1 HLM protein) are shown to introduce error arising from variability in unrelated, highly abundant proteins. Simulations of this variability suggest that up to 1.7-fold variation in apparent CYP3A4 abundance is artifactual, as are background positive correlations of up to 0.2 (Spearman correlation coefficient) between the abundances of DMEs. We suggest that protein concentrations used in pharmacokinetic predictions and scaling to in vivo clinical situations (physiologically based pharmacokinetics and in vitro-in vivo extrapolation) should be referenced instead to tissue mass. Copyright © 2017 by The American Society for Pharmacology and Experimental Therapeutics.

Breath acetone as a potential marker in clinical practice.

PubMed

Ruzsányi, Veronika; Péter Kalapos, Miklós

2017-06-01

In recent decades, two facts have changed the opinion of researchers about the function of acetone in humans. Firstly, it has turned out that acetone cannot be regarded as simply a waste product of metabolism, because there are several pathways in which acetone is produced or broken down. Secondly, methods have emerged making possible its detection in exhaled breath, thereby offering an attractive alternative to investigation of blood and urine samples. From a clinical point of view the measurement of breath acetone levels is important, but there are limitations to its wide application. These limitations can be divided into two classes, technical and biological limits. The technical limits include the storage of samples, detection threshold, standardization of clinical settings, and the price of instruments. When considering the biological ranges of acetone, personal factors such as race, age, gender, weight, food consumption, medication, illicit drugs, and even profession/class have to be taken into account to use concentration information for disorders. In some diseases such as diabetes mellitus and lung cancer, as well as in nutrition-related behavior such as starvation and ketogenic diet, breath acetone has been extensively examined. At the same time, there is a lack of investigations in other cases in which ketosis is also evident, such as in alcoholism or an inborn error of metabolism. In summary, the detection of acetone in exhaled breath is a useful and promising tool for diagnosis and it can be used as a marker to follow the effectiveness of treatments in some disorders. However, further endeavors are needed for clarification of the exact distribution of acetone in different body compartments and evaluation of its complex role in humans, especially in those cases in which a ketotic state also occurs.

Safety coaches in radiology: decreasing human error and minimizing patient harm.

PubMed

Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F

2010-09-01

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

Error-associated behaviors and error rates for robotic geology

NASA Technical Reports Server (NTRS)

Anderson, Robert C.; Thomas, Geb; Wagner, Jacob; Glasgow, Justin

2004-01-01

This study explores human error as a function of the decision-making process. One of many models for human decision-making is Rasmussen's decision ladder [9]. The decision ladder identifies the multiple tasks and states of knowledge involved in decision-making. The tasks and states of knowledge can be classified by the level of cognitive effort required to make the decision, leading to the skill, rule, and knowledge taxonomy (Rasmussen, 1987). Skill based decisions require the least cognitive effort and knowledge based decisions require the greatest cognitive effort. Errors can occur at any of the cognitive levels.

Procedural error monitoring and smart checklists

NASA Technical Reports Server (NTRS)

Palmer, Everett

1990-01-01

Human beings make and usually detect errors routinely. The same mental processes that allow humans to cope with novel problems can also lead to error. Bill Rouse has argued that errors are not inherently bad but their consequences may be. He proposes the development of error-tolerant systems that detect errors and take steps to prevent the consequences of the error from occurring. Research should be done on self and automatic detection of random and unanticipated errors. For self detection, displays should be developed that make the consequences of errors immediately apparent. For example, electronic map displays graphically show the consequences of horizontal flight plan entry errors. Vertical profile displays should be developed to make apparent vertical flight planning errors. Other concepts such as energy circles could also help the crew detect gross flight planning errors. For automatic detection, systems should be developed that can track pilot activity, infer pilot intent and inform the crew of potential errors before their consequences are realized. Systems that perform a reasonableness check on flight plan modifications by checking route length and magnitude of course changes are simple examples. Another example would be a system that checked the aircraft's planned altitude against a data base of world terrain elevations. Information is given in viewgraph form.

76 FR 77832 - Availability of Draft NTP Technical Reports; Request for Comments; Announcement of a Public...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-14

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Availability of Draft NTP Technical Reports; Request for Comments; Announcement of a Public Meeting To Peer Review Draft NTP Technical Reports AGENCY: National... Meeting. SUMMARY: The NTP announces the availability of seven draft NTP Technical Reports (TRs...

Technical and Vocational Education in Nigeria: Issues, Challenges and a Way Forward

ERIC Educational Resources Information Center

Okoye, Reko; Arimonu, Maxwell Onyenwe

2016-01-01

Technical education, as enshrined in the Nigerian national policy on education, is concerned with qualitative technological human resources development directed towards a national pool of skilled and self reliant craftsmen, technicians and technologists in technical and vocational education fields. In Nigeria, the training of technical personnel…

Technical match characteristics and influence of body anthropometry on playing performance in male elite team handball.

PubMed

Michalsik, Lars Bojsen; Madsen, Klavs; Aagaard, Per

2015-02-01

Modern team handball match-play imposes substantial physical and technical demands on elite players. However, only limited knowledge seems to exist about the specific working requirements in elite team handball. Thus, the purpose of this study was to examine the physical demands imposed on male elite team handball players in relation to playing position and body anthropometry. Based on continuous video recording of individual players during elite team handball match-play (62 tournament games, ∼4 players per game), computerized technical match analysis was performed in male elite team handball players along with anthropometric measurements over a 6 season time span. Technical match activities were distributed in 6 major types of playing actions (shots, breakthroughs, fast breaks, tackles, technical errors, and defense errors) and further divided into various subcategories (e.g., hard or light tackles, type of shot, claspings, screenings, and blockings). Players showed 36.9 ± 13.1 (group mean ± SD) high-intense technical playing actions per match with a mean total effective playing time of 53.85 ± 5.87 minutes. In offense, each player performed 6.0 ± 5.2 fast breaks, received 34.5 ± 21.3 tackles in total, and performed in defense 3.7 ± 3.5 blockings, 3.9 ± 3.0 claspings, and 5.8 ± 3.6 hard tackles. Wing players (84.5 ± 5.8 kg, 184.9 ± 5.7 cm) were less heavy and smaller (p < 0.001) than backcourt players (94.7 ± 7.1 kg, 191.9 ± 5.4 cm) and pivots (99.4 ± 6.2 kg, 194.8 ± 3.6 cm). In conclusion, modern male elite team handball match-play is characterized by a high number of short-term, high-intense intermittent technical playing actions. Indications of technical fatigue were observed. Physical demands differed between playing positions with wing players performing more fast breaks and less physical confrontations with opponent players than backcourt players and pivots. Body anthropometry seemed to have an important influence on playing performance because it is highly related to playing positions. The present observations suggest that male elite team handball players should implement more position-specific training regimens, while also focusing on anaerobic training and strength training.

Classifying health information technology patient safety related incidents - an approach used in Wales.

PubMed

Warm, D; Edwards, P

2012-01-01

Interest in the field of patient safety incident reporting and analysis with respect to Health Information Technology (HIT) has been growing over recent years as the development, implementation and reliance on HIT systems becomes ever more prevalent. One of the rationales for capturing patient safety incidents is to learn from failures in the delivery of care and must form part of a feedback loop which also includes analysis; investigation and monitoring. With the advent of new technologies and organizational programs of delivery the emphasis is increasingly upon analyzing HIT incidents. This thematic review had two objectives, to test the applicability of a framework specifically designed to categorize HIT incidents and to review the Welsh incidents as communicated via the national incident reporting system in order to understand their implications for healthcare. The incidents were those reported as IT/ telecommunications failure/ overload. Incidents were searched for within a national reporting system using a standardized search strategy for incidents occurring between 1(st) January 2009 and 31(st) May 2011. 149 incident reports were identified and classified. The majority (77%) of which were machine related (technical problems) such as access problems; computer system down/too slow; display issues; and software malfunctions. A further 10% (n = 15) of incidents were down to human-computer interaction issues and 13% (n = 19) incidents, mainly telephone related, could not be classified using the framework being tested. On the basis of this review of incidents, it is recommended that the framework be expanded to include hardware malfunctions and the wrong record retrieved/missing data associated with a machine output error (as opposed to human error). In terms of the implications for clinical practice, the incidents reviewed highlighted critical issues including the access problems particularly relating to the use of mobile technologies.

Dutch population specific sex estimation formulae using the proximal femur.

PubMed

Colman, K L; Janssen, M C L; Stull, K E; van Rijn, R R; Oostra, R J; de Boer, H H; van der Merwe, A E

2018-05-01

Sex estimation techniques are frequently applied in forensic anthropological analyses of unidentified human skeletal remains. While morphological sex estimation methods are able to endure population differences, the classification accuracy of metric sex estimation methods are population-specific. No metric sex estimation method currently exists for the Dutch population. The purpose of this study is to create Dutch population specific sex estimation formulae by means of osteometric analyses of the proximal femur. Since the Netherlands lacks a representative contemporary skeletal reference population, 2D plane reconstructions, derived from clinical computed tomography (CT) data, were used as an alternative source for a representative reference sample. The first part of this study assesses the intra- and inter-observer error, or reliability, of twelve measurements of the proximal femur. The technical error of measurement (TEM) and relative TEM (%TEM) were calculated using 26 dry adult femora. In addition, the agreement, or accuracy, between the dry bone and CT-based measurements was determined by percent agreement. Only reliable and accurate measurements were retained for the logistic regression sex estimation formulae; a training set (n=86) was used to create the models while an independent testing set (n=28) was used to validate the models. Due to high levels of multicollinearity, only single variable models were created. Cross-validated classification accuracies ranged from 86% to 92%. The high cross-validated classification accuracies indicate that the developed formulae can contribute to the biological profile and specifically in sex estimation of unidentified human skeletal remains in the Netherlands. Furthermore, the results indicate that clinical CT data can be a valuable alternative source of data when representative skeletal collections are unavailable. Copyright © 2017 Elsevier B.V. All rights reserved.

A circadian rhythm in skill-based errors in aviation maintenance.

PubMed

Hobbs, Alan; Williamson, Ann; Van Dongen, Hans P A

2010-07-01

In workplaces where activity continues around the clock, human error has been observed to exhibit a circadian rhythm, with a characteristic peak in the early hours of the morning. Errors are commonly distinguished by the nature of the underlying cognitive failure, particularly the level of intentionality involved in the erroneous action. The Skill-Rule-Knowledge (SRK) framework of Rasmussen is used widely in the study of industrial errors and accidents. The SRK framework describes three fundamental types of error, according to whether behavior is under the control of practiced sensori-motor skill routines with minimal conscious awareness; is guided by implicit or explicit rules or expertise; or where the planning of actions requires the conscious application of domain knowledge. Up to now, examinations of circadian patterns of industrial errors have not distinguished between different types of error. Consequently, it is not clear whether all types of error exhibit the same circadian rhythm. A survey was distributed to aircraft maintenance personnel in Australia. Personnel were invited to anonymously report a safety incident and were prompted to describe, in detail, the human involvement (if any) that contributed to it. A total of 402 airline maintenance personnel reported an incident, providing 369 descriptions of human error in which the time of the incident was reported and sufficient detail was available to analyze the error. Errors were categorized using a modified version of the SRK framework, in which errors are categorized as skill-based, rule-based, or knowledge-based, or as procedure violations. An independent check confirmed that the SRK framework had been applied with sufficient consistency and reliability. Skill-based errors were the most common form of error, followed by procedure violations, rule-based errors, and knowledge-based errors. The frequency of errors was adjusted for the estimated proportion of workers present at work/each hour of the day, and the 24 h pattern of each error type was examined. Skill-based errors exhibited a significant circadian rhythm, being most prevalent in the early hours of the morning. Variation in the frequency of rule-based errors, knowledge-based errors, and procedure violations over the 24 h did not reach statistical significance. The results suggest that during the early hours of the morning, maintenance technicians are at heightened risk of "absent minded" errors involving failures to execute action plans as intended.

Contribution to the Performance Determination of Microjets. Ph.D. Thesis - Technical Univ., Feb. 1983

NASA Technical Reports Server (NTRS)

Hayn, D.

1984-01-01

Theoretical investigations are made on the performance of microjets. A description is given of experiments with micropropulsion units to correlate the results obtained in the first part of the report. Execution of performance measurements is discussed, and error calculations are presented.

DETERMINING SPECIATION OF PB IN PHOSPHATE AMENDED SOILS: METHOD LIMITATIONS

EPA Science Inventory

Determining the effectiveness of in-situ immobilization for P-amended, Pb-contaminated soils has typically relied on non-spectroscopic methods that in recent years have come under scrutiny due to technical and unforeseen error issues. In this study, we analyzed 18 soil samples vi...

Using Media to Teach How Not to Do Psychotherapy

ERIC Educational Resources Information Center

Gabbard, Glen; Horowitz, Mardi

2010-01-01

Objective: This article describes how using media depictions of psychotherapy may help in teaching psychiatric residents. Methods: Using the HBO series "In Treatment" as a model, the authors suggest how boundary transgressions and technical errors may inform residents about optimal psychotherapeutic approaches. Results: The psychotherapy vignettes…

Publisher Correction: Cluster richness-mass calibration with cosmic microwave background lensing

NASA Astrophysics Data System (ADS)

Geach, James E.; Peacock, John A.

2018-03-01

Owing to a technical error, the `Additional information' section of the originally published PDF version of this Letter incorrectly gave J.A.P. as the corresponding author; it should have read J.E.G. This has now been corrected. The HTML version is correct.

Control of the exercise hyperpnoea in humans: a modeling perspective.

PubMed

Ward, S A

2000-09-01

Models of the exercise hyperpnoea have classically incorporated elements of proportional feedback (carotid and medullary chemosensory) and feedforward (central and/or peripheral neurogenic) control. However, the precise details of the control process remain unresolved, reflecting in part both technical and interpretational limitations inherent in isolating putative control mechanisms in the intact human, and also the challenges to linear control theory presented by multiple-input integration, especially with regard to the ventilatory and gas-exchange complexities encountered at work rates which engender a metabolic acidosis. While some combination of neurogenic, chemoreflex and circulatory-coupled processes are likely to contribute to the control, the system appears to evidence considerable redundancy. This, coupled with the lack of appreciable error signals in the mean levels of arterial blood gas tensions and pH over a wide range of work rates, has motivated the formulation of innovative control models that reflect not only spatial interactions but also temporal interactions (i.e. memory). The challenge is to discriminate between robust competing control models that: (a) integrate such processes within plausible physiological equivalents; and (b) account for both the dynamic and steady-state system response over a range of exercise intensities. Such models are not yet available.

Kinect technology for hand tracking control of surgical robots: technical and surgical skill comparison to current robotic masters.

PubMed

Kim, Yonjae; Leonard, Simon; Shademan, Azad; Krieger, Axel; Kim, Peter C W

2014-06-01

Current surgical robots are controlled by a mechanical master located away from the patient, tracking surgeon's hands by wire and pulleys or mechanical linkage. Contactless hand tracking for surgical robot control is an attractive alternative, because it can be executed with minimal footprint at the patient's bedside without impairing sterility, while eliminating current disassociation between surgeon and patient. We compared technical and technologic feasibility of contactless hand tracking to the current clinical standard master controllers. A hand-tracking system (Kinect™-based 3Gear), a wire-based mechanical master (Mantis Duo), and a clinical mechanical linkage master (da Vinci) were evaluated for technical parameters with strong clinical relevance: system latency, static noise, robot slave tremor, and controller range. Five experienced surgeons performed a skill comparison study, evaluating the three different master controllers for efficiency and accuracy in peg transfer and pointing tasks. da Vinci had the lowest latency of 89 ms, followed by Mantis with 374 ms and 3Gear with 576 ms. Mantis and da Vinci produced zero static error. 3Gear produced average static error of 0.49 mm. The tremor of the robot used by the 3Gear and Mantis system had a radius of 1.7 mm compared with 0.5 mm for da Vinci. The three master controllers all had similar range. The surgeons took 1.98 times longer to complete the peg transfer task with the 3Gear system compared with Mantis, and 2.72 times longer with Mantis compared with da Vinci (p value 2.1e-9). For the pointer task, surgeons were most accurate with da Vinci with average error of 0.72 mm compared with Mantis's 1.61 mm and 3Gear's 2.41 mm (p value 0.00078). Contactless hand-tracking technology as a surgical master can execute simple surgical tasks. Whereas traditional master controllers outperformed, given that contactless hand-tracking is a first-generation technology, clinical potential is promising and could become a reality with some technical improvements.

Innovative Socio-Technical Environments in Support of Distributed Intelligence and Lifelong Learning

ERIC Educational Resources Information Center

Fischer, G; Konomi, S.

2007-01-01

Individual, unaided human abilities are constrained. Media have helped us to transcend boundaries in thinking, working, learning and collaborating by supporting "distributed intelligence". Wireless and mobile technologies provide new opportunities for creating novel socio-technical environments and thereby empowering humans, but not without…

Spatial durbin error model for human development index in Province of Central Java.

NASA Astrophysics Data System (ADS)

Septiawan, A. R.; Handajani, S. S.; Martini, T. S.

2018-05-01

The Human Development Index (HDI) is an indicator used to measure success in building the quality of human life, explaining how people access development outcomes when earning income, health and education. Every year HDI in Central Java has improved to a better direction. In 2016, HDI in Central Java was 69.98 %, an increase of 0.49 % over the previous year. The objective of this study was to apply the spatial Durbin error model using angle weights queen contiguity to measure HDI in Central Java Province. Spatial Durbin error model is used because the model overcomes the spatial effect of errors and the effects of spatial depedency on the independent variable. Factors there use is life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity. Based on the result of research, we get spatial Durbin error model for HDI in Central Java with influencing factors are life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity.

Hierarchical learning induces two simultaneous, but separable, prediction errors in human basal ganglia.

PubMed

Diuk, Carlos; Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew; Niv, Yael

2013-03-27

Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously.

Mental representation of symbols as revealed by vocabulary errors in two bonobos (Pan paniscus).

PubMed

Lyn, Heidi

2007-10-01

Error analysis has been used in humans to detect implicit representations and categories in language use. The present study utilizes the same technique to report on mental representations and categories in symbol use from two bonobos (Pan paniscus). These bonobos have been shown in published reports to comprehend English at the level of a two-and-a-half year old child and to use a keyboard with over 200 visuographic symbols (lexigrams). In this study, vocabulary test errors from over 10 years of data revealed auditory, visual, and spatio-temporal generalizations (errors were more likely items that looked like sounded like, or were frequently associated with the sample item in space or in time), as well as hierarchical and conceptual categorizations. These error data, like those of humans, are a result of spontaneous responding rather than specific training and do not solely depend upon the sample mode (e.g. auditory similarity errors are not universally more frequent with an English sample, nor were visual similarity errors universally more frequent with a photograph sample). However, unlike humans, these bonobos do not make errors based on syntactical confusions (e.g. confusing semantically unrelated nouns), suggesting that they may not separate syntactical and semantic information. These data suggest that apes spontaneously create a complex, hierarchical, web of representations when exposed to a symbol system.

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.

Second Annual Workshop on Space Operations Automation and Robotics (SOAR 1988)

NASA Technical Reports Server (NTRS)

Griffin, Sandy (Editor)

1988-01-01

Papers presented at the Second Annual Workshop on Space Operation Automation and Robotics (SOAR '88), hosted by Wright State University at Dayton, Ohio, on July 20, 21, 22, and 23, 1988, are documented herein. During the 4 days, approximately 100 technical papers were presented by experts from NASA, the USAF, universities, and technical companies. Panel discussions on Human Factors, Artificial Intelligence, Robotics, and Space Systems were held but are not documented herein. Technical topics addressed included knowledge-based systems, human factors, and robotics.

Computerising the Salesforce: The Introduction of Technical Change in a Non-Union Workforce.

ERIC Educational Resources Information Center

Newell, Helen; Lloyd, Caroline

1998-01-01

Results of interviews with 13 pharmaceutical sales representatives, five sales managers, and six human-resource managers and 47 survey responses showed that introduction of information technology was seen as purely technical; human-resources departments played no role; and informal communication procedures enabled management to ignore individual…

45 CFR 1370.3 - Information and technical assistance center grants.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 4 2014-10-01 2014-10-01 false Information and technical assistance center grants. 1370.3 Section 1370.3 Public Welfare Regulations Relating to Public Welfare (Continued) OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES FAMILY VIOLENCE PREVENTION AND SERVICES PROGRAMS...

Spacecraft and propulsion technician error

NASA Astrophysics Data System (ADS)

Schultz, Daniel Clyde

Commercial aviation and commercial space similarly launch, fly, and land passenger vehicles. Unlike aviation, the U.S. government has not established maintenance policies for commercial space. This study conducted a mixed methods review of 610 U.S. space launches from 1984 through 2011, which included 31 failures. An analysis of the failure causal factors showed that human error accounted for 76% of those failures, which included workmanship error accounting for 29% of the failures. With the imminent future of commercial space travel, the increased potential for the loss of human life demands that changes be made to the standardized procedures, training, and certification to reduce human error and failure rates. Several recommendations were made by this study to the FAA's Office of Commercial Space Transportation, space launch vehicle operators, and maintenance technician schools in an effort to increase the safety of the space transportation passengers.

Simulation-based ureteroscopy skills training curriculum with integration of technical and non-technical skills: a randomised controlled trial.

PubMed

Brunckhorst, Oliver; Shahid, Shahab; Aydin, Abdullatif; McIlhenny, Craig; Khan, Shahid; Raza, Syed Johar; Sahai, Arun; Brewin, James; Bello, Fernando; Kneebone, Roger; Khan, Muhammad Shamim; Dasgupta, Prokar; Ahmed, Kamran

2015-09-01

Current training modalities within ureteroscopy have been extensively validated and must now be integrated within a comprehensive curriculum. Additionally, non-technical skills often cause surgical error and little research has been conducted to combine this with technical skills teaching. This study therefore aimed to develop and validate a curriculum for semi-rigid ureteroscopy, integrating both technical and non-technical skills teaching within the programme. Delphi methodology was utilised for curriculum development and content validation, with a randomised trial then conducted (n = 32) for curriculum evaluation. The developed curriculum consisted of four modules; initially developing basic technical skills and subsequently integrating non-technical skills teaching. Sixteen participants underwent the simulation-based curriculum and were subsequently assessed, together with the control cohort (n = 16) within a full immersion environment. Both technical (Time to completion, OSATS and a task specific checklist) and non-technical (NOTSS) outcome measures were recorded with parametric and non-parametric analyses used depending on the distribution of our data as evaluated by a Shapiro-Wilk test. Improvements within the intervention cohort demonstrated educational value across all technical and non-technical parameters recorded, including time to completion (p < 0.01), OSATS scores (p < 0.001), task specific checklist scores (p = 0.011) and NOTSS scores (p < 0.001). Content validity, feasibility and acceptability were all demonstrated through curriculum development and post-study questionnaire results. The current developed curriculum demonstrates that integrating both technical and non-technical skills teaching is both educationally valuable and feasible. Additionally, the curriculum offers a validated simulation-based training modality within ureteroscopy and a framework for the development of other simulation-based programmes.

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 3.552 - Harmless error.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Harmless error. 3.552 Section 3.552 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Enforcement Program § 3.552 Harmless error. No error in either the...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 1 2011-10-01 2011-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

Defense Mapping Agency (DMA) Raster-to-Vector Analysis

DTIC Science & Technology

1984-11-30

model) to pinpoint critical deficiencies and understand trade-offs between alternative solutions. This may be exemplified by the allocation of human ...process, prone to errors (i.e., human operator eye/motor control limitations), and its time consuming nature (as a function of data density). It should...achieved through the facilities of coinputer interactive graphics. Each error or anomaly is individually identified by a human operator and corrected

Head Start Impact Study. Technical Report

ERIC Educational Resources Information Center

Puma, Michael; Bell, Stephen; Cook, Ronna; Heid, Camilla; Shapiro, Gary; Broene, Pam; Jenkins, Frank; Fletcher, Philip; Quinn, Liz; Friedman, Janet; Ciarico, Janet; Rohacek, Monica; Adams, Gina; Spier, Elizabeth

2010-01-01

This Technical Report is designed to provide technical detail to support the analysis and findings presented in the "Head Start Impact Study Final Report" (U.S. Department of Health and Human Services, January 2010). Chapter 1 provides an overview of the Head Start Impact Study and its findings. Chapter 2 provides technical information on the…

The Predictive Validity of the Minnesota Reading Assessment for Students in Postsecondary Vocational Education Programs.

ERIC Educational Resources Information Center

Brown, James M.; Chang, Gerald

1982-01-01

The predictive validity of the Minnesota Reading Assessment (MRA) when used to project potential performance of postsecondary vocational-technical education students was examined. Findings confirmed the MRA to be a valid predictor, although the error in prediction varied between the criterion variables. (Author/GK)

Flight Technical Error for Category B Non-Precision Approaches and Missed Approaches Using Non-Differential GPS for Course Guidance

DOT National Transportation Integrated Search

1993-11-01

Twelve general aviation pilots flew a Beechcraft Baron on 93 non-precision instrument approaches using a nondifferential : GPS receiver nodifled to satisfy selected functional requirements specified in TS0-C129. : The purposes of the effort were to d...

78 FR 18974 - Increasing Market and Planning Efficiency Through Improved Software; Notice of Technical...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-28

... bring together experts from diverse backgrounds and experiences including electric system operators... transmission switching; AC optimal power flow modeling; and use of active and dynamic transmission ratings. In... variability of the system, including forecast error? [cir] How can outage probability be captured in...

77 FR 52035 - Public Information Collection Requirements Submitted to the Office of Management and Budget (OMB...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-28

... Identifier: CMS-10003] Public Information Collection Requirements Submitted to the Office of Management and Budget (OMB); Correction AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Correction of notice. SUMMARY: This document corrects a technical error in the notice [Document Identifier: CMS...

Online Hand Holding in Fixing Computer Glitches

ERIC Educational Resources Information Center

Goldsborough, Reid

2005-01-01

According to most surveys, computer manufacturers such as HP puts out reliable products, and computers in general are less troublesome than in the past. But personal computers are still prone to bugs, conflicts, viruses, spyware infestations, hacker and phishing attacks, and--most of all--user error. Unfortunately, technical support from computer…

How we learn to make decisions: rapid propagation of reinforcement learning prediction errors in humans.

PubMed

Krigolson, Olav E; Hassall, Cameron D; Handy, Todd C

2014-03-01

Our ability to make decisions is predicated upon our knowledge of the outcomes of the actions available to us. Reinforcement learning theory posits that actions followed by a reward or punishment acquire value through the computation of prediction errors-discrepancies between the predicted and the actual reward. A multitude of neuroimaging studies have demonstrated that rewards and punishments evoke neural responses that appear to reflect reinforcement learning prediction errors [e.g., Krigolson, O. E., Pierce, L. J., Holroyd, C. B., & Tanaka, J. W. Learning to become an expert: Reinforcement learning and the acquisition of perceptual expertise. Journal of Cognitive Neuroscience, 21, 1833-1840, 2009; Bayer, H. M., & Glimcher, P. W. Midbrain dopamine neurons encode a quantitative reward prediction error signal. Neuron, 47, 129-141, 2005; O'Doherty, J. P. Reward representations and reward-related learning in the human brain: Insights from neuroimaging. Current Opinion in Neurobiology, 14, 769-776, 2004; Holroyd, C. B., & Coles, M. G. H. The neural basis of human error processing: Reinforcement learning, dopamine, and the error-related negativity. Psychological Review, 109, 679-709, 2002]. Here, we used the brain ERP technique to demonstrate that not only do rewards elicit a neural response akin to a prediction error but also that this signal rapidly diminished and propagated to the time of choice presentation with learning. Specifically, in a simple, learnable gambling task, we show that novel rewards elicited a feedback error-related negativity that rapidly decreased in amplitude with learning. Furthermore, we demonstrate the existence of a reward positivity at choice presentation, a previously unreported ERP component that has a similar timing and topography as the feedback error-related negativity that increased in amplitude with learning. The pattern of results we observed mirrored the output of a computational model that we implemented to compute reward prediction errors and the changes in amplitude of these prediction errors at the time of choice presentation and reward delivery. Our results provide further support that the computations that underlie human learning and decision-making follow reinforcement learning principles.

Causal Evidence from Humans for the Role of Mediodorsal Nucleus of the Thalamus in Working Memory.

PubMed

Peräkylä, Jari; Sun, Lihua; Lehtimäki, Kai; Peltola, Jukka; Öhman, Juha; Möttönen, Timo; Ogawa, Keith H; Hartikainen, Kaisa M

2017-12-01

The mediodorsal nucleus of the thalamus (MD), with its extensive connections to the lateral pFC, has been implicated in human working memory and executive functions. However, this understanding is based solely on indirect evidence from human lesion and imaging studies and animal studies. Direct, causal evidence from humans is missing. To obtain direct evidence for MD's role in humans, we studied patients treated with deep brain stimulation (DBS) for refractory epilepsy. This treatment is thought to prevent the generalization of a seizure by disrupting the functioning of the patient's anterior nuclei of the thalamus (ANT) with high-frequency electric stimulation. This structure is located superior and anterior to MD, and when the DBS lead is implanted in ANT, tip contacts of the lead typically penetrate through ANT into the adjoining MD. To study the role of MD in human executive functions and working memory, we periodically disrupted and recovered MD's function with high-frequency electric stimulation using DBS contacts reaching MD while participants performed a cognitive task engaging several aspects of executive functions. We hypothesized that the efficacy of executive functions, specifically working memory, is impaired when the functioning of MD is perturbed by high-frequency stimulation. Eight participants treated with ANT-DBS for refractory epilepsy performed a computer-based test of executive functions while DBS was repeatedly switched ON and OFF at MD and at the control location (ANT). In comparison to stimulation of the control location, when MD was stimulated, participants committed 2.26 times more errors in general (total errors; OR = 2.26, 95% CI [1.69, 3.01]) and 2.86 times more working memory-related errors specifically (incorrect button presses; OR = 2.88, CI [1.95, 4.24]). Similarly, participants committed 1.81 more errors in general ( OR = 1.81, CI [1.45, 2.24]) and 2.08 times more working memory-related errors ( OR = 2.08, CI [1.57, 2.75]) in comparison to no stimulation condition. "Total errors" is a composite score consisting of basic error types and was mostly driven by working memory-related errors. The facts that MD and a control location, ANT, are only few millimeters away from each other and that their stimulation produces very different results highlight the location-specific effect of DBS rather than regionally unspecific general effect. In conclusion, disrupting and recovering MD's function with high-frequency electric stimulation modulated participants' online working memory performance providing causal, in vivo evidence from humans for the role of MD in human working memory.

Understanding situation awareness and its importance in patient safety.

PubMed

Gluyas, Heather; Harris, Sarah-Jane

2016-04-20

Situation awareness describes an individual's perception, comprehension and subsequent projection of what is going on in the environment around them. The concept of situation awareness sits within the group of non-technical skills that include teamwork, communication and managing hierarchical lines of communication. The importance of non-technical skills has been recognised in safety-critical industries such as aviation, the military, nuclear, and oil and gas. However, health care has been slow to embrace the role of non-technical skills such as situation awareness in improving outcomes and minimising the risk of error. This article explores the concept of situation awareness and the cognitive processes involved in maintaining it. In addition, factors that lead to a loss of situation awareness and strategies to improve situation awareness are discussed.

A distributed and intelligent system approach for the automatic inspection of steam-generator tubes in nuclear power plants

NASA Astrophysics Data System (ADS)

Kang, Soon Ju; Moon, Jae Chul; Choi, Doo-Hyun; Choi, Sung Su; Woo, Hee Gon

1998-06-01

The inspection of steam-generator (SG) tubes in a nuclear power plant (NPP) is a time-consuming, laborious, and hazardous task because of several hard constraints such as a highly radiated working environment, a tight task schedule, and the need for many experienced human inspectors. This paper presents a new distributed intelligent system architecture for automating traditional inspection methods. The proposed architecture adopts three basic technical strategies in order to reduce the complexity of system implementation. The first is the distributed task allocation into four stages: inspection planning (IF), signal acquisition (SA), signal evaluation (SE), and inspection data management (IDM). Consequently, dedicated subsystems for automation of each stage can be designed and implemented separately. The second strategy is the inclusion of several useful artificial intelligence techniques for implementing the subsystems of each stage, such as an expert system for IP and SE and machine vision and remote robot control techniques for SA. The third strategy is the integration of the subsystems using client/server-based distributed computing architecture and a centralized database management concept. Through the use of the proposed architecture, human errors, which can occur during inspection, can be minimized because the element of human intervention has been almost eliminated; however, the productivity of the human inspector can be increased equally. A prototype of the proposed system has been developed and successfully tested over the last six years in domestic NPP's.

A Method for the Study of Human Factors in Aircraft Operations

NASA Technical Reports Server (NTRS)

Barnhart, W.; Billings, C.; Cooper, G.; Gilstrap, R.; Lauber, J.; Orlady, H.; Puskas, B.; Stephens, W.

1975-01-01

A method for the study of human factors in the aviation environment is described. A conceptual framework is provided within which pilot and other human errors in aircraft operations may be studied with the intent of finding out how, and why, they occurred. An information processing model of human behavior serves as the basis for the acquisition and interpretation of information relating to occurrences which involve human error. A systematic method of collecting such data is presented and discussed. The classification of the data is outlined.

An interactive framework for acquiring vision models of 3-D objects from 2-D images.

PubMed

Motai, Yuichi; Kak, Avinash

2004-02-01

This paper presents a human-computer interaction (HCI) framework for building vision models of three-dimensional (3-D) objects from their two-dimensional (2-D) images. Our framework is based on two guiding principles of HCI: 1) provide the human with as much visual assistance as possible to help the human make a correct input; and 2) verify each input provided by the human for its consistency with the inputs previously provided. For example, when stereo correspondence information is elicited from a human, his/her job is facilitated by superimposing epipolar lines on the images. Although that reduces the possibility of error in the human marked correspondences, such errors are not entirely eliminated because there can be multiple candidate points close together for complex objects. For another example, when pose-to-pose correspondence is sought from a human, his/her job is made easier by allowing the human to rotate the partial model constructed in the previous pose in relation to the partial model for the current pose. While this facility reduces the incidence of human-supplied pose-to-pose correspondence errors, such errors cannot be eliminated entirely because of confusion created when multiple candidate features exist close together. Each input provided by the human is therefore checked against the previous inputs by invoking situation-specific constraints. Different types of constraints (and different human-computer interaction protocols) are needed for the extraction of polygonal features and for the extraction of curved features. We will show results on both polygonal objects and object containing curved features.

New methodology to reconstruct in 2-D the cuspal enamel of modern human lower molars.

PubMed

Modesto-Mata, Mario; García-Campos, Cecilia; Martín-Francés, Laura; Martínez de Pinillos, Marina; García-González, Rebeca; Quintino, Yuliet; Canals, Antoni; Lozano, Marina; Dean, M Christopher; Martinón-Torres, María; Bermúdez de Castro, José María

2017-08-01

In the last years different methodologies have been developed to reconstruct worn teeth. In this article, we propose a new 2-D methodology to reconstruct the worn enamel of lower molars. Our main goals are to reconstruct molars with a high level of accuracy when measuring relevant histological variables and to validate the methodology calculating the errors associated with the measurements. This methodology is based on polynomial regression equations, and has been validated using two different dental variables: cuspal enamel thickness and crown height of the protoconid. In order to perform the validation process, simulated worn modern human molars were employed. The associated errors of the measurements were also estimated applying methodologies previously proposed by other authors. The mean percentage error estimated in reconstructed molars for these two variables in comparison with their own real values is -2.17% for the cuspal enamel thickness of the protoconid and -3.18% for the crown height of the protoconid. This error significantly improves the results of other methodologies, both in the interobserver error and in the accuracy of the measurements. The new methodology based on polynomial regressions can be confidently applied to the reconstruction of cuspal enamel of lower molars, as it improves the accuracy of the measurements and reduces the interobserver error. The present study shows that it is important to validate all methodologies in order to know the associated errors. This new methodology can be easily exportable to other modern human populations, the human fossil record and forensic sciences. © 2017 Wiley Periodicals, Inc.

Safety and Performance Analysis of the Non-Radar Oceanic/Remote Airspace In-Trail Procedure

NASA Technical Reports Server (NTRS)

Carreno, Victor A.; Munoz, Cesar A.

2007-01-01

This document presents a safety and performance analysis of the nominal case for the In-Trail Procedure (ITP) in a non-radar oceanic/remote airspace. The analysis estimates the risk of collision between the aircraft performing the ITP and a reference aircraft. The risk of collision is only estimated for the ITP maneuver and it is based on nominal operating conditions. The analysis does not consider human error, communication error conditions, or the normal risk of flight present in current operations. The hazards associated with human error and communication errors are evaluated in an Operational Hazards Analysis presented elsewhere.

Tutorial on Reed-Solomon error correction coding

NASA Technical Reports Server (NTRS)

Geisel, William A.

1990-01-01

This tutorial attempts to provide a frank, step-by-step approach to Reed-Solomon (RS) error correction coding. RS encoding and RS decoding both with and without erasing code symbols are emphasized. There is no need to present rigorous proofs and extreme mathematical detail. Rather, the simple concepts of groups and fields, specifically Galois fields, are presented with a minimum of complexity. Before RS codes are presented, other block codes are presented as a technical introduction into coding. A primitive (15, 9) RS coding example is then completely developed from start to finish, demonstrating the encoding and decoding calculations and a derivation of the famous error-locator polynomial. The objective is to present practical information about Reed-Solomon coding in a manner such that it can be easily understood.

Risk management at the stage of design of high-rise construction facilities

NASA Astrophysics Data System (ADS)

Politi, Violetta

2018-03-01

This paper describes the assessment of the probabilistic risk of an accident formed in the process of designing a technically complex facility. It considers values of conditional probabilities of the compliance of load-bearing structures with safety requirements, provides an approximate list of significant errors of the designer and analyzes the relationship between the degree of compliance and the level of danger of errors. It describes and proposes for implementation the regulated procedures related to the assessment of the safety level of constructive solutions and the reliability of the construction process participants.

A cognitive taxonomy of medical errors.

PubMed

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

2004-06-01

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

Differential sensitivity to human communication in dogs, wolves, and human infants.

PubMed

Topál, József; Gergely, György; Erdohegyi, Agnes; Csibra, Gergely; Miklósi, Adám

2009-09-04

Ten-month-old infants persistently search for a hidden object at its initial hiding place even after observing it being hidden at another location. Recent evidence suggests that communicative cues from the experimenter contribute to the emergence of this perseverative search error. We replicated these results with dogs (Canis familiaris), who also commit more search errors in ostensive-communicative (in 75% of the total trials) than in noncommunicative (39%) or nonsocial (17%) hiding contexts. However, comparative investigations suggest that communicative signals serve different functions for dogs and infants, whereas human-reared wolves (Canis lupus) do not show doglike context-dependent differences of search errors. We propose that shared sensitivity to human communicative signals stems from convergent social evolution of the Homo and the Canis genera.

Metrics for Business Process Models

NASA Astrophysics Data System (ADS)

Mendling, Jan

Up until now, there has been little research on why people introduce errors in real-world business process models. In a more general context, Simon [404] points to the limitations of cognitive capabilities and concludes that humans act rationally only to a certain extent. Concerning modeling errors, this argument would imply that human modelers lose track of the interrelations of large and complex models due to their limited cognitive capabilities and introduce errors that they would not insert in a small model. A recent study by Mendling et al. [275] explores in how far certain complexity metrics of business process models have the potential to serve as error determinants. The authors conclude that complexity indeed appears to have an impact on error probability. Before we can test such a hypothesis in a more general setting, we have to establish an understanding of how we can define determinants that drive error probability and how we can measure them.

Hierarchical Learning Induces Two Simultaneous, But Separable, Prediction Errors in Human Basal Ganglia

PubMed Central

Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew

2013-01-01

Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously. PMID:23536092

Wrist electrogoniometry: are current mathematical correction procedures effective in reducing crosstalk in functional assessment?

PubMed

Foltran, Fabiana A; Silva, Luciana C C B; Sato, Tatiana O; Coury, Helenice J C G

2013-01-01

The recording of human movement is an essential requirement for biomechanical, clinical, and occupational analysis, allowing assessment of postural variation, occupational risks, and preventive programs in physical therapy and rehabilitation. The flexible electrogoniometer (EGM), considered a reliable and accurate device, is used for dynamic recordings of different joints. Despite these advantages, the EGM is susceptible to measurement errors, known as crosstalk. There are two known types of crosstalk: crosstalk due to sensor rotation and inherent crosstalk. Correction procedures have been proposed to correct these errors; however no study has used both procedures in clinical measures for wrist movements with the aim to optimize the correction. To evaluate the effects of mathematical correction procedures on: 1) crosstalk due to forearm rotation, 2) inherent sensor crosstalk; and 3) the combination of these two procedures. 43 healthy subjects had their maximum range of motion of wrist flexion/extension and ulnar/radials deviation recorded by EGM. The results were analyzed descriptively, and procedures were compared by differences. There was no significant difference in measurements before and after the application of correction procedures (P<0.05). Furthermore, the differences between the correction procedures were less than 5° in most cases, having little impact on the measurements. Considering the time-consuming data analysis, the specific technical knowledge involved, and the inefficient results, the correction procedures are not recommended for wrist recordings by EGM.

Technical note: A linear model for predicting δ13 Cprotein.

PubMed

Pestle, William J; Hubbe, Mark; Smith, Erin K; Stevenson, Joseph M

2015-08-01

Development of a model for the prediction of δ(13) Cprotein from δ(13) Ccollagen and Δ(13) Cap-co . Model-generated values could, in turn, serve as "consumer" inputs for multisource mixture modeling of paleodiet. Linear regression analysis of previously published controlled diet data facilitated the development of a mathematical model for predicting δ(13) Cprotein (and an experimentally generated error term) from isotopic data routinely generated during the analysis of osseous remains (δ(13) Cco and Δ(13) Cap-co ). Regression analysis resulted in a two-term linear model (δ(13) Cprotein (%) = (0.78 × δ(13) Cco ) - (0.58× Δ(13) Cap-co ) - 4.7), possessing a high R-value of 0.93 (r(2)  = 0.86, P < 0.01), and experimentally generated error terms of ±1.9% for any predicted individual value of δ(13) Cprotein . This model was tested using isotopic data from Formative Period individuals from northern Chile's Atacama Desert. The model presented here appears to hold significant potential for the prediction of the carbon isotope signature of dietary protein using only such data as is routinely generated in the course of stable isotope analysis of human osseous remains. These predicted values are ideal for use in multisource mixture modeling of dietary protein source contribution. © 2015 Wiley Periodicals, Inc.

Associations between errors and contributing factors in aircraft maintenance

NASA Technical Reports Server (NTRS)

Hobbs, Alan; Williamson, Ann

2003-01-01

In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.

Neuroanatomical dissociation for taxonomic and thematic knowledge in the human brain

PubMed Central

Schwartz, Myrna F.; Kimberg, Daniel Y.; Walker, Grant M.; Brecher, Adelyn; Faseyitan, Olufunsho K.; Dell, Gary S.; Mirman, Daniel; Coslett, H. Branch

2011-01-01

It is thought that semantic memory represents taxonomic information differently from thematic information. This study investigated the neural basis for the taxonomic-thematic distinction in a unique way. We gathered picture-naming errors from 86 individuals with poststroke language impairment (aphasia). Error rates were determined separately for taxonomic errors (“pear” in response to apple) and thematic errors (“worm” in response to apple), and their shared variance was regressed out of each measure. With the segmented lesions normalized to a common template, we carried out voxel-based lesion-symptom mapping on each error type separately. We found that taxonomic errors localized to the left anterior temporal lobe and thematic errors localized to the left temporoparietal junction. This is an indication that the contribution of these regions to semantic memory cleaves along taxonomic-thematic lines. Our findings show that a distinction long recognized in the psychological sciences is grounded in the structure and function of the human brain. PMID:21540329

Interspecies scaling and prediction of human clearance: comparison of small- and macro-molecule drugs

PubMed Central

Huh, Yeamin; Smith, David E.; Feng, Meihau Rose

2014-01-01

Human clearance prediction for small- and macro-molecule drugs was evaluated and compared using various scaling methods and statistical analysis.Human clearance is generally well predicted using single or multiple species simple allometry for macro- and small-molecule drugs excreted renally.The prediction error is higher for hepatically eliminated small-molecules using single or multiple species simple allometry scaling, and it appears that the prediction error is mainly associated with drugs with low hepatic extraction ratio (Eh). The error in human clearance prediction for hepatically eliminated small-molecules was reduced using scaling methods with a correction of maximum life span (MLP) or brain weight (BRW).Human clearance of both small- and macro-molecule drugs is well predicted using the monkey liver blood flow method. Predictions using liver blood flow from other species did not work as well, especially for the small-molecule drugs. PMID:21892879

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.

EDI and the Technical Communicator.

ERIC Educational Resources Information Center

Eiler, Mary Ann

1994-01-01

Assesses the role of technical communicators in electronic data interchange (EDI). Argues that, as experts in information design, human factors, instructional theory, and professional writing, technical communicators should be advocates of standard documentation protocols and should rethink the traditional concepts of "document" to…

A Case Study on the Status of Technical and Vocational Education in Thailand. Case Studies on Technical and Vocational Education in Asia and the Pacific.

ERIC Educational Resources Information Center

Shoolap, Charoon; Choomnoom, Siripan

This two-part report presents an overview of the vocational and technical education system in Thailand. The first part is a review of the current and likely future situations pertaining to vocational and technical education in that country. An analysis of economic conditions, human resource development, and the existing technical and vocational…

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

Using SAS PROC CALIS to fit Level-1 error covariance structures of latent growth models.

PubMed

Ding, Cherng G; Jane, Ten-Der

2012-09-01

In the present article, we demonstrates the use of SAS PROC CALIS to fit various types of Level-1 error covariance structures of latent growth models (LGM). Advantages of the SEM approach, on which PROC CALIS is based, include the capabilities of modeling the change over time for latent constructs, measured by multiple indicators; embedding LGM into a larger latent variable model; incorporating measurement models for latent predictors; and better assessing model fit and the flexibility in specifying error covariance structures. The strength of PROC CALIS is always accompanied with technical coding work, which needs to be specifically addressed. We provide a tutorial on the SAS syntax for modeling the growth of a manifest variable and the growth of a latent construct, focusing the documentation on the specification of Level-1 error covariance structures. Illustrations are conducted with the data generated from two given latent growth models. The coding provided is helpful when the growth model has been well determined and the Level-1 error covariance structure is to be identified.

Fifty Years of THERP and Human Reliability Analysis

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

Ronald L. Boring

2012-06-01

In 1962 at a Human Factors Society symposium, Alan Swain presented a paper introducing a Technique for Human Error Rate Prediction (THERP). This was followed in 1963 by a Sandia Laboratories monograph outlining basic human error quantification using THERP and, in 1964, by a special journal edition of Human Factors on quantification of human performance. Throughout the 1960s, Swain and his colleagues focused on collecting human performance data for the Sandia Human Error Rate Bank (SHERB), primarily in connection with supporting the reliability of nuclear weapons assembly in the US. In 1969, Swain met with Jens Rasmussen of Risø Nationalmore » Laboratory and discussed the applicability of THERP to nuclear power applications. By 1975, in WASH-1400, Swain had articulated the use of THERP for nuclear power applications, and the approach was finalized in the watershed publication of the NUREG/CR-1278 in 1983. THERP is now 50 years old, and remains the most well known and most widely used HRA method. In this paper, the author discusses the history of THERP, based on published reports and personal communication and interviews with Swain. The author also outlines the significance of THERP. The foundations of human reliability analysis are found in THERP: human failure events, task analysis, performance shaping factors, human error probabilities, dependence, event trees, recovery, and pre- and post-initiating events were all introduced in THERP. While THERP is not without its detractors, and it is showing signs of its age in the face of newer technological applications, the longevity of THERP is a testament of its tremendous significance. THERP started the field of human reliability analysis. This paper concludes with a discussion of THERP in the context of newer methods, which can be seen as extensions of or departures from Swain’s pioneering work.« less

Lessons for surgeons in the final moments of Air France Flight 447.

PubMed

Bhangu, Aneel; Bhangu, Sonia; Stevenson, James; Bowley, Douglas M

2013-06-01

All surgeons make mistakes, and learning from critical incidents may help improve performance. The present study aimed to highlight lessons for surgeons from analysis of the final moments of Air France Flight 447. All of the authors work in teams and situations where safety, technical performance, and non-technical skills are critical. This review was born out of discussions regarding the events of Flight 447; specifically, whether the airline disaster was relevant to their work, and whether they could learn anything from it. The study is based on review of the crash reports of Flight 447, which lost flight speed indication after formation of ice prevented air from entering flight speed indicators during a storm. Following a subsequent stall, the aircraft fell at a rate of >10,000 feet/min until it crashed into the Atlantic Ocean, killing 228 passengers and crew. There were errors in decision making, reasoning, communication, and teamwork. Such non-technical skills failures have been recognized previously and can be addressed by existing non-technical skills training. A reliance on autopilot meant that the pilots were unfamiliar with high-altitude flying when the autopilot is disengaged. They were unprepared for and affected by such a sudden and serious problem; an event called "surprise and startle" by the accident investigation. The absence of the senior pilot (who was on a scheduled break) in the critical final minutes slowed error recognition and recovery. Unintended consequences of modern safety strategies may be under-recognized and can lead to adverse events. Both simulation-based and non-simulation-based training should include "surprise and startle" events beyond the scenarios trainees might expect. Likewise, in the face of increasing reliance on modern technology, surgeons should ensure that they would be able to perform procedures in the absence of such technologies. Specific training may improve surgeons' non-technical skills, and recognition of such skills could also be used to help select future surgeons.

Error-free replicative bypass of (6–4) photoproducts by DNA polymerase ζ in mouse and human cells

PubMed Central

Yoon, Jung-Hoon; Prakash, Louise; Prakash, Satya

2010-01-01

The ultraviolet (UV)-induced (6–4) pyrimidine–pyrimidone photoproduct [(6–4) PP] confers a large structural distortion in DNA. Here we examine in human cells the roles of translesion synthesis (TLS) DNA polymerases (Pols) in promoting replication through a (6–4) TT photoproduct carried on a duplex plasmid where bidirectional replication initiates from an origin of replication. We show that TLS contributes to a large fraction of lesion bypass and that it is mostly error-free. We find that, whereas Pol η and Pol ι provide alternate pathways for mutagenic TLS, surprisingly, Pol ζ functions independently of these Pols and in a predominantly error-free manner. We verify and extend these observations in mouse cells and conclude that, in human cells, TLS during replication can be markedly error-free even opposite a highly distorting DNA lesion. PMID:20080950

A Framework for Modeling Human-Machine Interactions

NASA Technical Reports Server (NTRS)

Shafto, Michael G.; Rosekind, Mark R. (Technical Monitor)

1996-01-01

Modern automated flight-control systems employ a variety of different behaviors, or modes, for managing the flight. While developments in cockpit automation have resulted in workload reduction and economical advantages, they have also given rise to an ill-defined class of human-machine problems, sometimes referred to as 'automation surprises'. Our interest in applying formal methods for describing human-computer interaction stems from our ongoing research on cockpit automation. In this area of aeronautical human factors, there is much concern about how flight crews interact with automated flight-control systems, so that the likelihood of making errors, in particular mode-errors, is minimized and the consequences of such errors are contained. The goal of the ongoing research on formal methods in this context is: (1) to develop a framework for describing human interaction with control systems; (2) to formally categorize such automation surprises; and (3) to develop tests for identification of these categories early in the specification phase of a new human-machine system.

Inborn Errors of Human JAKs and STATs

PubMed Central

Casanova, Jean-Laurent; Holland, Steven M.; Notarangelo, Luigi D.

2012-01-01

Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying bi-allelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high level of allelic heterogeneity at the human JAK3, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. PMID:22520845

Inborn errors of human JAKs and STATs.

PubMed

Casanova, Jean-Laurent; Holland, Steven M; Notarangelo, Luigi D

2012-04-20

Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying biallelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high degree of allelic heterogeneity at the human JAK3, TYK2, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. Copyright © 2012 Elsevier Inc. All rights reserved.

Use of modeling to identify vulnerabilities to human error in laparoscopy.

PubMed

Funk, Kenneth H; Bauer, James D; Doolen, Toni L; Telasha, David; Nicolalde, R Javier; Reeber, Miriam; Yodpijit, Nantakrit; Long, Myra

2010-01-01

This article describes an exercise to investigate the utility of modeling and human factors analysis in understanding surgical processes and their vulnerabilities to medical error. A formal method to identify error vulnerabilities was developed and applied to a test case of Veress needle insertion during closed laparoscopy. A team of 2 surgeons, a medical assistant, and 3 engineers used hierarchical task analysis and Integrated DEFinition language 0 (IDEF0) modeling to create rich models of the processes used in initial port creation. Using terminology from a standardized human performance database, detailed task descriptions were written for 4 tasks executed in the process of inserting the Veress needle. Key terms from the descriptions were used to extract from the database generic errors that could occur. Task descriptions with potential errors were translated back into surgical terminology. Referring to the process models and task descriptions, the team used a modified failure modes and effects analysis (FMEA) to consider each potential error for its probability of occurrence, its consequences if it should occur and be undetected, and its probability of detection. The resulting likely and consequential errors were prioritized for intervention. A literature-based validation study confirmed the significance of the top error vulnerabilities identified using the method. Ongoing work includes design and evaluation of procedures to correct the identified vulnerabilities and improvements to the modeling and vulnerability identification methods. Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.

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

PubMed Central

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

2018-01-01

Background Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. Methods We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. Results We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Conclusions Standard error-checking techniques may not identify all errors in spreadsheet-based models. Comparing parallel model versions can aid in identifying unintentional errors and promoting reliable model projections, particularly when resources are limited. PMID:29570737

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

PubMed

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

2018-01-01

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

Sustainability of protocolized handover of pediatric cardiac surgery patients to the intensive care unit.

PubMed

Chenault, Kristin; Moga, Michael-Alice; Shin, Minah; Petersen, Emily; Backer, Carl; De Oliveira, Gildasio S; Suresh, Santhanam

2016-05-01

Transfer of patient care among clinicians (handovers) is a common source of medical errors. While the immediate efficacy of these initiatives is well documented, sustainability of practice changes that results in better processes of care is largely understudied. The objective of the current investigation was to evaluate the sustainability of a protocolized handover process in pediatric patients from the operating room after cardiac surgery to the intensive care unit. This was a prospective study with direct observation assessment of handover performance conducted in the cardiac ICU (CICU) of a free-standing, tertiary care children's hospital in the United States. Patient transitions from the operating room to the CICU, including the verbal handoff, were directly observed by a single independent observer in all phases of the study. A checklist of key elements identified errors classified as: (1) technical, (2) information omissions, and (3) realized errors. Total number of errors was compared across the different times of the study (preintervention, postintervention, and the current sustainability phase). A total of 119 handovers were studied: 41 preintervention, 38 postintervention, and 40 in the current sustainability phase. The median [Interquartile range (IQR)] number of technical errors was significantly reduced in the sustainability phase compared to the preintervention and postintervention phase, 2 (1-3), 6 (5-7), and 2.5 (2-4), respectively P = 0.0001. Similarly, the median (IQR) number of verbal information omissions was also significantly reduced in the sustainability phase compared to the preintervention and postintervention phases, 1 (1-1), 4 (3-5) and 2 (1-3), respectively. We demonstrate sustainability of an improved handover process using a checklist in children being transferred to the intensive care unit after cardiac surgery. Standardized handover processes can be a sustainable strategy to improve patient safety after pediatric cardiac surgery. © 2016 John Wiley & Sons Ltd.

Detection of Error Related Neuronal Responses Recorded by Electrocorticography in Humans during Continuous Movements

PubMed Central

Milekovic, Tomislav; Ball, Tonio; Schulze-Bonhage, Andreas; Aertsen, Ad; Mehring, Carsten

2013-01-01

Background Brain-machine interfaces (BMIs) can translate the neuronal activity underlying a user’s movement intention into movements of an artificial effector. In spite of continuous improvements, errors in movement decoding are still a major problem of current BMI systems. If the difference between the decoded and intended movements becomes noticeable, it may lead to an execution error. Outcome errors, where subjects fail to reach a certain movement goal, are also present during online BMI operation. Detecting such errors can be beneficial for BMI operation: (i) errors can be corrected online after being detected and (ii) adaptive BMI decoding algorithm can be updated to make fewer errors in the future. Methodology/Principal Findings Here, we show that error events can be detected from human electrocorticography (ECoG) during a continuous task with high precision, given a temporal tolerance of 300–400 milliseconds. We quantified the error detection accuracy and showed that, using only a small subset of 2×2 ECoG electrodes, 82% of detection information for outcome error and 74% of detection information for execution error available from all ECoG electrodes could be retained. Conclusions/Significance The error detection method presented here could be used to correct errors made during BMI operation or to adapt a BMI algorithm to make fewer errors in the future. Furthermore, our results indicate that smaller ECoG implant could be used for error detection. Reducing the size of an ECoG electrode implant used for BMI decoding and error detection could significantly reduce the medical risk of implantation. PMID:23383315

Research on calibration error of carrier phase against antenna arraying

NASA Astrophysics Data System (ADS)

Sun, Ke; Hou, Xiaomin

2016-11-01

It is the technical difficulty of uplink antenna arraying that signals from various quarters can not be automatically aligned at the target in deep space. The size of the far-field power combining gain is directly determined by the accuracy of carrier phase calibration. It is necessary to analyze the entire arraying system in order to improve the accuracy of the phase calibration. This paper analyzes the factors affecting the calibration error of carrier phase of uplink antenna arraying system including the error of phase measurement and equipment, the error of the uplink channel phase shift, the position error of ground antenna, calibration receiver and target spacecraft, the error of the atmospheric turbulence disturbance. Discuss the spatial and temporal autocorrelation model of atmospheric disturbances. Each antenna of the uplink antenna arraying is no common reference signal for continuous calibration. So it must be a system of the periodic calibration. Calibration is refered to communication of one or more spacecrafts in a certain period. Because the deep space targets are not automatically aligned to multiplexing received signal. Therefore the aligned signal should be done in advance on the ground. Data is shown that the error can be controlled within the range of demand by the use of existing technology to meet the accuracy of carrier phase calibration. The total error can be controlled within a reasonable range.

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

Using lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose".

PubMed

Ching, Joan M; Williams, Barbara L; Idemoto, Lori M; Blackmore, C Craig

2014-08-01

Virginia Mason Medical Center (Seattle) employed the Lean concept of Jidoka (automation with a human touch) to plan for and deploy bar code medication administration (BCMA) to hospitalized patients. Integrating BCMA technology into the nursing work flow with minimal disruption was accomplished using three steps ofJidoka: (1) assigning work to humans and machines on the basis of their differing abilities, (2) adapting machines to the human work flow, and (3) monitoring the human-machine interaction. Effectiveness of BCMA to both reinforce safe administration practices and reduce medication errors was measured using the Collaborative Alliance for Nursing Outcomes (CALNOC) Medication Administration Accuracy Quality Study methodology. Trained nurses observed a total of 16,149 medication doses for 3,617 patients in a three-year period. Following BCMA implementation, the number of safe practice violations decreased from 54.8 violations/100 doses (January 2010-September 2011) to 29.0 violations/100 doses (October 2011-December 2012), resulting in an absolute risk reduction of 25.8 violations/100 doses (95% confidence interval [CI]: 23.7, 27.9, p < .001). The number of medication errors decreased from 5.9 errors/100 doses at baseline to 3.0 errors/100 doses after BCMA implementation (absolute risk reduction: 2.9 errors/100 doses [95% CI: 2.2, 3.6,p < .001]). The number of unsafe administration practices (estimate, -5.481; standard error 1.133; p < .001; 95% CI: -7.702, -3.260) also decreased. As more hospitals respond to health information technology meaningful use incentives, thoughtful, methodical, and well-managed approaches to technology deployment are crucial. This work illustrates how Jidoka offers opportunities for a smooth transition to new technology.

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

PubMed Central

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

2014-01-01

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

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

PubMed

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

2014-10-01

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

SIMBIOS Project

NASA Technical Reports Server (NTRS)

Fargion, Giulietta S.; McClain, Charles R.

2002-01-01

The purpose of this technical report is to provide current documentation of the Sensor Intercomparison and Merger for Biological and Interdisciplinary Oceanic Studies (SIMBIOS) Project activities, NASA Research Announcement (NRA) research status, satellite data processing, data product validation, and field calibration. This documentation is necessary to ensure that critical information is related to the scientific community and NASA management. This critical information includes the technical difficulties and challenges of validating and combining ocean color data from an array of independent satellite systems to form consistent and accurate global bio-optical time series products. This technical report is not meant as a substitute for scientific literature. Instead, it will provide a ready and responsive vehicle for the multitude of technical reports issued by an operational project. The SIMBIOS Science Team Principal Investigators' (PIs) original contributions to this report are in chapters four and above. The purpose of these contributions is to describe the current research status of the SIMBIOS-NRA-96 funded research. The contributions are published as submitted, with the exception of minor edits to correct obvious grammatical or clerical errors.

Evaluating the Performance Diagnostic Checklist-Human Services to Assess Incorrect Error-Correction Procedures by Preschool Paraprofessionals

ERIC Educational Resources Information Center

Bowe, Melissa; Sellers, Tyra P.

2018-01-01

The Performance Diagnostic Checklist-Human Services (PDC-HS) has been used to assess variables contributing to undesirable staff performance. In this study, three preschool teachers completed the PDC-HS to identify the factors contributing to four paraprofessionals' inaccurate implementation of error-correction procedures during discrete trial…

The Importance of HRA in Human Space Flight: Understanding the Risks

NASA Technical Reports Server (NTRS)

Hamlin, Teri

2010-01-01

Human performance is critical to crew safety during space missions. Humans interact with hardware and software during ground processing, normal flight, and in response to events. Human interactions with hardware and software can cause Loss of Crew and/or Vehicle (LOCV) through improper actions, or may prevent LOCV through recovery and control actions. Humans have the ability to deal with complex situations and system interactions beyond the capability of machines. Human Reliability Analysis (HRA) is a method used to qualitatively and quantitatively assess the occurrence of human failures that affect availability and reliability of complex systems. Modeling human actions with their corresponding failure probabilities in a Probabilistic Risk Assessment (PRA) provides a more complete picture of system risks and risk contributions. A high-quality HRA can provide valuable information on potential areas for improvement, including training, procedures, human interfaces design, and the need for automation. Modeling human error has always been a challenge in part because performance data is not always readily available. For spaceflight, the challenge is amplified not only because of the small number of participants and limited amount of performance data available, but also due to the lack of definition of the unique factors influencing human performance in space. These factors, called performance shaping factors in HRA terminology, are used in HRA techniques to modify basic human error probabilities in order to capture the context of an analyzed task. Many of the human error modeling techniques were developed within the context of nuclear power plants and therefore the methodologies do not address spaceflight factors such as the effects of microgravity and longer duration missions. This presentation will describe the types of human error risks which have shown up as risk drivers in the Shuttle PRA which may be applicable to commercial space flight. As with other large PRAs of complex machines, human error in the Shuttle PRA proved to be an important contributor (12 percent) to LOCV. An existing HRA technique was adapted for use in the Shuttle PRA, but additional guidance and improvements are needed to make the HRA task in space-related PRAs easier and more accurate. Therefore, this presentation will also outline plans for expanding current HRA methodology to more explicitly cover spaceflight performance shaping factors.

Technical Quality of Root Canal Treatment Performed by Undergraduate Clinical Students of Isfahan Dental School.

PubMed

Saatchi, Masoud; Mohammadi, Golshan; Vali Sichani, Armita; Moshkforoush, Saba

2018-01-01

The aim of the present study was to evaluate the radiographic quality of RCTs performed by undergraduate clinical students of Dental School of Isfahan University of Medical Sciences. In this cross sectional study, records and periapical radiographs of 1200 root filled teeth were randomly selected from the records of patients who had received RCTs in Dental School of Isfahan University of Medical Sciences from 2013 to 2015. After excluding 416 records, the final sample consisted of 784 root-treated teeth (1674 root canals). Two variables including the length and the density of the root fillings were examined. Moreover, the presence of ledge, foramen perforation, root perforation and fractured instruments were also evaluated as procedural errors. Descriptive statistics were used for expressing the frequencies of criteria and chi square test was used for comparing tooth types, tooth locations and academic level of students ( P <0.05). The frequency of root canals with acceptable filling was 54.1%. Overfilling was found in 11% of root canals, underfilling in 8.3% and inadequate density in 34.6%. No significant difference was found between the frequency of acceptable root fillings in the maxilla and mandible ( P =0.072). More acceptable fillings were found in the root canals of premolars (61.3%) than molars (51.3%) ( P =0.001). The frequency of procedural errors was 18.6%. Ledge was found in 12.5% of root canals, foramen perforation in 2%, root perforation in 2.4% and fractured instrument in 2%. Procedural errors were more frequent in the root canals of molars (22.5%) than the anterior teeth (12.3%) ( P =0.003) and the premolars (9.5%) ( P <0.001). Technical quality of RCTs performed by clinical students was not satisfactory and incidence of procedural errors was considerable.

Comment on "Differential sensitivity to human communication in dogs, wolves, and human infants".

PubMed

Fiset, Sylvain

2010-07-09

Topál et al. (Reports, 4 September 2009, p. 1269) reported that dogs' sensitivity to reading and using human signals contributes to the emergence of a spatial perseveration error (the A-not-B error) for locating objects. Here, I argue that the authors' conclusion was biased by two confounding factors: the use of an atypical A-not-B search task and an inadequate nonsocial condition as a control.

NASA: Model development for human factors interfacing

NASA Technical Reports Server (NTRS)

Smith, L. L.

1984-01-01

The results of an intensive literature review in the general topics of human error analysis, stress and job performance, and accident and safety analysis revealed no usable techniques or approaches for analyzing human error in ground or space operations tasks. A task review model is described and proposed to be developed in order to reduce the degree of labor intensiveness in ground and space operations tasks. An extensive number of annotated references are provided.

Problems with the Use of Terminology in Genetics Education: 1, A Literature Review and Classification Scheme.

ERIC Educational Resources Information Center

Pearson, J. T.; Hughes, W. J.

1988-01-01

Examines the technical vocabulary of genetics as a source of error and confusion. Suggests that it is necessary to identify different types of problems associated with terminology and to organize them into logical classes to deal effectively with the difficulties. Highlights terms misused in textbooks. (RT)

The Coast Artillery Journal. Volume 74, Number 5, July-August 1931

DTIC Science & Technology

1931-08-01

adhering to the principle when faced with the fact of war. Finally, none of the former Allies feel that the Zoll- Yerein-Anschluss-::\\Iittel Europa issue...jngs published in Ordnance Technical Notes Xo. 5 and Proving Ground probable errors for the 16-inch gun at quadrant elevation.., from 45 to 65

75 FR 52446 - CBP Dec. 10-29; Technical Corrections to Customs and Border Protection Regulations

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-26

... that the importing and general public are aware of CBP programs, requirements, and procedures regarding... Stat. 2597. Therefore, in order to reflect the inclusion of clerical error, mistake of fact, or other... certification of origin import requirements under the United States-Chile Free Trade Agreement (CFTA), contains...

78 FR 18526 - Significant New Use Rules on Certain Chemical Substances; Technical Amendment

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-27

... aromatic sulfonic acid amino azo dye salts (PMN P-12-276) a typographical error has been identified. This... significant new uses for aromatic sulfonic acid amino azo dye salts, EPA inadvertently listed the respirator... include this requirement when promulgating the significant new uses for aromatic sulfonic acid amino azo...

Evaluating Procedures for Reducing Measurement Error in Math Curriculum-Based Measurement Probes

ERIC Educational Resources Information Center

Methe, Scott A.; Briesch, Amy M.; Hulac, David

2015-01-01

At present, it is unclear whether math curriculum-based measurement (M-CBM) procedures provide a dependable measure of student progress in math computation because support for its technical properties is based largely upon a body of correlational research. Recent investigations into the dependability of M-CBM scores have found that evaluating…

50 CFR 23.53 - What are the requirements for obtaining a retrospective CITES document?

Code of Federal Regulations, 2010 CFR

2010-10-01

... section have been met. (5) The issuing Management Authority must provide all of the following information... sufficient information for us to find that your activity meets all of the following criteria: (1) The... a technical error that was not prompted by information provided by the applicant when issuing the...

FNOC In Situ Technical Support.

DTIC Science & Technology

1982-10-01

09 NM2*20 MSGLINE*14 CONJDP*04 SEXY *05 CON VERT*O7 ACOULAB ACOULAB*06 Correct meter to feet conversion error (if more 20SVP pt). DATE ROUTINE... PORN , TASS, and PTARF (MOFT produces ASRAPL & BLKDATA for FASOTRAGRU moffett). (DRUN*106 S2 4682) B-9 UPDTE DATE: 12/15/81*1 .- PROGRAM PROGRAMMER

An Analysis of Fifth-Grade Students' Performance When Solving Selected Open Distributive Sentences. Technical Report No. 397.

ERIC Educational Resources Information Center

Hobbs, Charles Eugene

The author investigates elementary school students' performance when solving selected open distributive sentences in relation to three factors (Open Sentence Type, Context, Number Size) and identifies and classifies solution methods attempted by students and students' errors in performance. Eighty fifth-grade students participated in the…

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

Not Available

At the request of the Office of Solid Wastes (OSW), the SAB's Environmental Engineering Committee reviewed a draft Agency guidance for the establishment of Alternate Concentration Limits (ACL) for Resource Conservation and Recovery Act (RCRA) facilities, and two case studies demonstrating applications of the guidance. The Committee identified only obvious technical errors or omissions, which are explained in detail in the report.

Reconstructive Recall of Linguistic Style. Technical Report No. 286.

ERIC Educational Resources Information Center

Brewer, William F.; Hay, Anne E.

A study investigated reconstructive recall for linguistic style. It was hypothesized that (1) features of linguistic style would be more difficult to recall than underlying content, (2) reconstructive errors would include stylistic forms recalled as standard forms when subjects lacked productive control of a particular feature of a style, and (3)…

Wilderness Crisis Management. Explore Magazine Technical Series No. 11.

ERIC Educational Resources Information Center

Raffan, James

This paper deals with managing a crisis in a wilderness situation. The terms "crisis" and "turning point" are used to describe what is more traditionally called an accident. Using these terms introduces the idea that crisis events occur as logical consequences of preceding decisions, errors, or omissions, not as the result of…

A Survey of Progress in Coding Theory in the Soviet Union. Final Report.

ERIC Educational Resources Information Center

Kautz, William H.; Levitt, Karl N.

The results of a comprehensive technical survey of all published Soviet literature in coding theory and its applications--over 400 papers and books appearing before March 1967--are described in this report. Noteworthy Soviet contributions are discussed, including codes for the noiseless channel, codes that correct asymetric errors, decoding for…

Hazardous Waste Treatment, Storage, and Disposal Facilities-Organic Air Emission Standards for Process Vents and Equipment Leaks - Technical Amendment - Federal Register Notice, April 26, 1991

EPA Pesticide Factsheets

This document corrects typographical errors in the regulatory text of the final standards that would limit organic air emissions as a class at hazardous waste treatment, storage, and disposal facilities (TSDF) that are subject to regulation under subtitle

Designing to Control Flight Crew Errors

NASA Technical Reports Server (NTRS)

Schutte, Paul C.; Willshire, Kelli F.

1997-01-01

It is widely accepted that human error is a major contributing factor in aircraft accidents. There has been a significant amount of research in why these errors occurred, and many reports state that the design of flight deck can actually dispose humans to err. This research has led to the call for changes in design according to human factors and human-centered principles. The National Aeronautics and Space Administration's (NASA) Langley Research Center has initiated an effort to design a human-centered flight deck from a clean slate (i.e., without constraints of existing designs.) The effort will be based on recent research in human-centered design philosophy and mission management categories. This design will match the human's model of the mission and function of the aircraft to reduce unnatural or non-intuitive interfaces. The product of this effort will be a flight deck design description, including training and procedures, and a cross reference or paper trail back to design hypotheses, and an evaluation of the design. The present paper will discuss the philosophy, process, and status of this design effort.

Electronic health systems: challenges faced by hospital-based providers.

PubMed

Agno, Christina Farala; Guo, Kristina L

2013-01-01

The purpose of this article is to discuss specific challenges faced by hospitals adopting the use of electronic medical records and implementing electronic health record (EHR) systems. Challenges include user and information technology support; ease of technical use and software interface capabilities; compliance; and financial, legal, workforce training, and development issues. Electronic health records are essential to preventing medical errors, increasing consumer trust and use of the health system, and improving quality and overall efficiency. Government efforts are focused on ways to accelerate the adoption and use of EHRs as a means of facilitating data sharing, protecting health information privacy and security, quickly identifying emerging public health threats, and reducing medical errors and health care costs and increasing quality of care. This article will discuss physician and nonphysician staff training before, during, and after implementation; the effective use of EHR systems' technical features; the selection of a capable and secure EHR system; and the development of collaborative system implementation. Strategies that are necessary to help health care providers achieve successful implementation of EHR systems will be addressed.

Spatial variation in the degradation rate of the pesticides isoproturon, azoxystrobin and diflufenican in soil and its relationship with chemical and microbial properties.

PubMed

Bending, Gary D; Lincoln, Suzanne D; Edmondson, Rodney N

2006-01-01

The extent of within field variability in the degradation rate of the pesticides isoproturon, azoxystrobin and diflufenican, and the role of intrinsic soil factors and technical errors in contributing to the variability, was investigated in sites on sandy-loam and clay-loam. At each site, 40 topsoil samples were taken from a 160 x 60 m area, and pesticides applied in the laboratory. Time to 25% dissipation (DT25) ranged between 13 and 61 weeks for diflufenican, 5.6 and 17.2 weeks for azoxystrobin, and 0.3 and 12.5 weeks for isoproturon. Variability in DT25 was higher in the sandy-loam in which there was also greatest variability in soil chemical and microbial properties. Technical error associated with pesticide extraction, analysis and lack of model fit during derivation of DT25 accounted for between 5.3 and 25.8% of the variability for isoproturon and azoxystrobin, but could account for almost all the variability for diflufenican. Azoxystrobin DT25, sorption and pH were significantly correlated.

Methodological, technical, and ethical issues of a computerized data system.

PubMed

Rice, C A; Godkin, M A; Catlin, R J

1980-06-01

This report examines some methodological, technical, and ethical issues which need to be addressed in designing and implementing a valid and reliable computerized clinical data base. The report focuses on the data collection system used by four residency based family health centers, affiliated with the University of Massachusetts Medical Center. It is suggested that data reliability and validity can be maximized by: (1) standardizing encounter forms at affiliated health centers to eliminate recording biases and ensure data comparability; (2) using forms with a diagnosis checklist to reduce coding errors and increase the number of diagnoses recorded per encounter; (3) developing uniform diagnostic criteria; (4) identifying sources of error, including discrepancies of clinical data as recorded in medical records, encounter forms, and the computer; and (5) improving provider cooperation in recording data by distributing data summaries which reinforce the data's applicability to service provision. Potential applications of the data for research purposes are restricted by personnel and computer costs, confidentiality considerations, programming related issues, and, most importantly, health center priorities, largely focused on patient care, not research.

Advancing Usability Evaluation through Human Reliability Analysis

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

Ronald L. Boring; David I. Gertman

2005-07-01

This paper introduces a novel augmentation to the current heuristic usability evaluation methodology. The SPAR-H human reliability analysis method was developed for categorizing human performance in nuclear power plants. Despite the specialized use of SPAR-H for safety critical scenarios, the method also holds promise for use in commercial off-the-shelf software usability evaluations. The SPAR-H method shares task analysis underpinnings with human-computer interaction, and it can be easily adapted to incorporate usability heuristics as performance shaping factors. By assigning probabilistic modifiers to heuristics, it is possible to arrive at the usability error probability (UEP). This UEP is not a literal probabilitymore » of error but nonetheless provides a quantitative basis to heuristic evaluation. When combined with a consequence matrix for usability errors, this method affords ready prioritization of usability issues.« less

Design Guidelines and Criteria for User/Operator Transactions with Battlefield Automated Systems. Volume I. Executive Summary

DTIC Science & Technology

1981-02-01

SUMMARY Robert N. Parrish, Jesse L. Gates, and Sarah J. Munger SYNECTICS CORPORATION HUMAN FACTORS TECHNICAL AREA L.. .iU. S. Army Research Institute for...of the Human Factors Technical Area, ARI, is the Contracting Officer’s Representative (COR) for this project. 19. KEY WORDS (Continue on reverse...aide It neceeary ad Identify by block number) Battlefield automated systems Human -computer interaction Design criteria System analysis Design guidelines

Physician assistants and the disclosure of medical error.

PubMed

Brock, Douglas M; Quella, Alicia; Lipira, Lauren; Lu, Dave W; Gallagher, Thomas H

2014-06-01

Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

75 FR 15342 - Advisory Committees; Technical Amendment

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-29

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration 21 CFR Part 14 [Docket No. FDA-2010-N-0001] Advisory Committees; Technical Amendment Agency: Food and Drug Administration, HHS. ACTION: Final rule; technical amendment. SUMMARY: The Food and Drug Administration (FDA) is amending its...

Humanistic Elements in the Educational Practice at a United States Sub-Baccalaureate Technical College

ERIC Educational Resources Information Center

Chen, Peng; Schmidtke, Carsten

2017-01-01

Humanism has never been able to establish a firm place in technical education, which remains predominantly pragmatist in response to industry needs, certification requirements and educational standardisation. However, after a period of decline, humanism has made somewhat of a comeback as part of the movement toward student-centred education.…

Miniature Telerobots in Space Applications

NASA Technical Reports Server (NTRS)

Venema, S. C.; Hannaford, B.

1995-01-01

Ground controlled telerobots can be used to reduce astronaut workload while retaining much of the human capabilities of planning, execution, and error recovery for specific tasks. Miniature robots can be used for delicate and time consuming tasks such as biological experiment servicing without incurring the significant mass and power penalties associated with larger robot systems. However, questions remain regarding the technical and economic effectiveness of such mini-telerobotic systems. This paper address some of these open issues and the details of two projects which will provide some of the needed answers. The Microtrex project is a joint University of Washington/NASA project which plans on flying a miniature robot as a Space Shuttle experiment to evaluate the effects of microgravity on ground-controlled manipulation while subject to variable time-delay communications. A related project involving the University of Washington and Boeing Defense and Space will evaluate the effectiveness f using a minirobot to service biological experiments in a space station experiment 'glove-box' rack mock-up, again while subject to realistic communications constraints.

Pitfalls in genetic testing: the story of missed SCN1A mutations.

PubMed

Djémié, Tania; Weckhuysen, Sarah; von Spiczak, Sarah; Carvill, Gemma L; Jaehn, Johanna; Anttonen, Anna-Kaisa; Brilstra, Eva; Caglayan, Hande S; de Kovel, Carolien G; Depienne, Christel; Gaily, Eija; Gennaro, Elena; Giraldez, Beatriz G; Gormley, Padhraig; Guerrero-López, Rosa; Guerrini, Renzo; Hämäläinen, Eija; Hartmann, Corinna; Hernandez-Hernandez, Laura; Hjalgrim, Helle; Koeleman, Bobby P C; Leguern, Eric; Lehesjoki, Anna-Elina; Lemke, Johannes R; Leu, Costin; Marini, Carla; McMahon, Jacinta M; Mei, Davide; Møller, Rikke S; Muhle, Hiltrud; Myers, Candace T; Nava, Caroline; Serratosa, Jose M; Sisodiya, Sanjay M; Stephani, Ulrich; Striano, Pasquale; van Kempen, Marjan J A; Verbeek, Nienke E; Usluer, Sunay; Zara, Federico; Palotie, Aarno; Mefford, Heather C; Scheffer, Ingrid E; De Jonghe, Peter; Helbig, Ingo; Suls, Arvid

2016-07-01

Sanger sequencing, still the standard technique for genetic testing in most diagnostic laboratories and until recently widely used in research, is gradually being complemented by next-generation sequencing (NGS). No single mutation detection technique is however perfect in identifying all mutations. Therefore, we wondered to what extent inconsistencies between Sanger sequencing and NGS affect the molecular diagnosis of patients. Since mutations in SCN1A, the major gene implicated in epilepsy, are found in the majority of Dravet syndrome (DS) patients, we focused on missed SCN1A mutations. We sent out a survey to 16 genetic centers performing SCN1A testing. We collected data on 28 mutations initially missed using Sanger sequencing. All patients were falsely reported as SCN1A mutation-negative, both due to technical limitations and human errors. We illustrate the pitfalls of Sanger sequencing and most importantly provide evidence that SCN1A mutations are an even more frequent cause of DS than already anticipated.

Simulation-Based Assessment Identifies Longitudinal Changes in Cognitive Skills in an Anesthesiology Residency Training Program.

PubMed

Sidi, Avner; Gravenstein, Nikolaus; Vasilopoulos, Terrie; Lampotang, Samsun

2017-06-02

We describe observed improvements in nontechnical or "higher-order" deficiencies and cognitive performance skills in an anesthesia residency cohort for a 1-year time interval. Our main objectives were to evaluate higher-order, cognitive performance and to demonstrate that simulation can effectively serve as an assessment of cognitive skills and can help detect "higher-order" deficiencies, which are not as well identified through more traditional assessment tools. We hypothesized that simulation can identify longitudinal changes in cognitive skills and that cognitive performance deficiencies can then be remediated over time. We used 50 scenarios evaluating 35 residents during 2 subsequent years, and 18 of those 35 residents were evaluated in both years (post graduate years 3 then 4) in the same or similar scenarios. Individual basic knowledge and cognitive performance during simulation-based scenarios were assessed using a 20- to 27-item scenario-specific checklist. Items were labeled as basic knowledge/technical (lower-order cognition) or advanced cognitive/nontechnical (higher-order cognition). Identical or similar scenarios were repeated annually by a subset of 18 residents during 2 successive academic years. For every scenario and item, we calculated group error scenario rate (frequency) and individual (resident) item success. Grouped individuals' success rates are calculated as mean (SD), and item success grade and group error rates are calculated and presented as proportions. For all analyses, α level is 0.05. Overall PGY4 residents' error rates were lower and success rates higher for the cognitive items compared with technical item performance in the operating room and resuscitation domains. In all 3 clinical domains, the cognitive error rate by PGY4 residents was fairly low (0.00-0.22) and the cognitive success rate by PGY4 residents was high (0.83-1.00) and significantly better compared with previous annual assessments (P < 0.05). Overall, there was an annual decrease in error rates for 2 years, primarily driven by decreases in cognitive errors. The most commonly observed cognitive error types remained anchoring, availability bias, premature closure, and confirmation bias. Simulation-based assessments can highlight cognitive performance areas of relative strength, weakness, and progress in a resident or resident cohort. We believe that they can therefore be used to inform curriculum development including activities that require higher-level cognitive processing.

Autonomous Control Modes and Optimized Path Guidance for Shipboard Landing in High Sea States

DTIC Science & Technology

2015-11-16

a degraded visual environment, workload during the landing task begins to approach the limits of a human pilot’s capability. It is a similarly...Figure 2. Approach Trajectory ±4 ft landing error ±8 ft landing error ±12 ft landing error Flight Path -3000...heave and yaw axes. Figure 5. Open loop system generation ±4 ft landing error ±8 ft landing error ±12 ft landing error -10 -8 -6 -4 -2 0 2 4

3D Model Generation From the Engineering Drawing

NASA Astrophysics Data System (ADS)

Vaský, Jozef; Eliáš, Michal; Bezák, Pavol; Červeňanská, Zuzana; Izakovič, Ladislav

2010-01-01

The contribution deals with the transformation of engineering drawings in a paper form into a 3D computer representation. A 3D computer model can be further processed in CAD/CAM system, it can be modified, archived, and a technical drawing can be then generated from it as well. The transformation process from paper form to the data one is a complex and difficult one, particularly owing to the different types of drawings, forms of displayed objects and encountered errors and deviations from technical standards. The algorithm for 3D model generating from an orthogonal vector input representing a simplified technical drawing of the rotational part is described in this contribution. The algorithm was experimentally implemented as ObjectARX application in the AutoCAD system and the test sample as the representation of the rotational part was used for verificaton.

Selecting a software development methodology. [of digital flight control systems

NASA Technical Reports Server (NTRS)

Jones, R. E.

1981-01-01

The state of the art analytical techniques for the development and verification of digital flight control software is studied and a practical designer oriented development and verification methodology is produced. The effectiveness of the analytic techniques chosen for the development and verification methodology are assessed both technically and financially. Technical assessments analyze the error preventing and detecting capabilities of the chosen technique in all of the pertinent software development phases. Financial assessments describe the cost impact of using the techniques, specifically, the cost of implementing and applying the techniques as well as the relizable cost savings. Both the technical and financial assessment are quantitative where possible. In the case of techniques which cannot be quantitatively assessed, qualitative judgements are expressed about the effectiveness and cost of the techniques. The reasons why quantitative assessments are not possible will be documented.