Relevant bibliographies by topics / Reports of errors

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  2. Dissertations / Theses
  3. Books
  4. Book chapters
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Academic literature on the topic 'Reports of errors'

Author: Grafiati
Published: 4 June 2021
Last updated: 1 February 2022

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Journal articles on the topic "Reports of errors"

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Leddin, Desmond. "Alpha Errors, Beta Errors and Negative Trials." Canadian Journal of Gastroenterology 2, no. 4 (1988): 147–50. http://dx.doi.org/10.1155/1988/523841.

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Reports of negative trials arc increasing in number as standard therapy for many gastrointestinal diseases is refined. The validity of a negative report depends on the number of patients in the trial, the alpha and bern error and the difference in efficacy which the trial is able to detect. The relationship between these parameters is discussed and a formula given for the calculation of trial size. All reports of negative trials should include not only the number of patients involved and the level of significance of the results but also the beta error and the detectable difference in efficacy of the treatments.
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Mathiowetz, Nancy A. "Errors in Reports of Occupation." Public Opinion Quarterly 56, no. 3 (1992): 352. http://dx.doi.org/10.1086/269327.

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Dalmolin, Gabriella Rejane dos Santos, Eloni Terezinha Rotta, and José Roberto Goldim. "Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital." Brazilian Journal of Pharmaceutical Sciences 49, no. 4 (2013): 793–802. http://dx.doi.org/10.1590/s1984-82502013000400019.

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Medication errors can be frequent in hospitals; these errors are multidisciplinary and occur at various stages of the drug therapy. The present study evaluated the seriousness, the type and the drugs involved in medication errors reported at the Hospital de Clínicas de Porto Alegre. We analyzed written error reports for 2010-2011. The sample consisted of 165 reports. The errors identified were classified according to seriousness, type and pharmacological class. 114 reports were categorized as actual errors (medication errors) and 51 reports were categorized as potential errors. There were more medication error reports in 2011 compared to 2010, but there was no significant change in the seriousness of the reports. The most common type of error was prescribing error (48.25%). Errors that occurred during the process of drug therapy sometimes generated additional medication errors. In 114 reports of medication errors identified, 122 drugs were cited. The reflection on medication errors, the possibility of harm resulting from these errors, and the methods for error identification and evaluation should include a broad perspective of the aspects involved in the occurrence of errors. Patient safety depends on the process of communication involving errors, on the proper recording of information, and on the monitoring itself.
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Dreijer, Albert R., Jeroen Diepstraten, Vera E. Bukkems, et al. "Anticoagulant medication errors in hospitals and primary care: a cross-sectional study." International Journal for Quality in Health Care 31, no. 5 (2018): 346–52. http://dx.doi.org/10.1093/intqhc/mzy177.

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Abstract Objective To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase). Design A cross-sectional study. Setting Medication errors reported to the Central Medication incidents Registration reporting system. Participants Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR. Intervention N/A. Main outcome measure Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline. Results Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline. Conclusions Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.
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Merrick, Joav, and Kenneth Koslowe. "Refractive errors and visual anomalies in Down syndrome." Down Syndrome Research and Practice 6, no. 3 (2001): 131–33. http://dx.doi.org/10.3104/reports.105.

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Rohatgi, Radha, and Sadhna Shankar. "Chemotherapy Related Errors in the Pediatric Oncology Unit At a Tertiary Care Institution,." Blood 118, no. 21 (2011): 4197. http://dx.doi.org/10.1182/blood.v118.21.4197.4197.

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Abstract Abstract 4197 Medication errors are responsible for 98,000 deaths and over almost a million injuries every year according to the Institute of Medicine report published in 1999. Cancer patients often receive complicated chemotherapy regimens which are at risk for errors. Few studies have evaluated the risk of medication errors related to chemotherapy. Majority of these studies are related to adult cancer patients. Studies regarding chemotherapy errors in pediatric patients are limited. The goal of this study was to evaluate the type and severity of errors related to chemotherapy administration in the pediatric oncology inpatient unit and outpatient clinic at a single institution over a 24 month period using a voluntary error reporting system in the institution. WebEnvision is a voluntary electronic reporting system implemented in 2007, that allows staff to anonymously report patient or staff safety incidents. We evaluated all the chemotherapy related WebEnvision reports from June 1, 2009 to May 31, 2011. All reports related to prescribing, dispensing and administering chemotherapy medications were included. Reports related to a supportive care measures were excluded. The reports were reviewed by both authors and graded according to the National Coordinating Council for Medication Error Reporting and Prevention Index for medication errors. The errors were also classified by type as defined by the American Society of Hospital Pharmacists guidelines for preventing medication errors. A total of 1030 reports related to oncology patients were recorded during the study period. Of these, 246 (23.9%) were related to chemotherapy. Thirty nine thousand preparations were dispensed by the chemotherapy pharmacy during the study period. The median number of chemotherapy drugs on orders associated with an error was 2 with a range of 1 to 6. The median length of chemotherapy treatment per order was 3 days with a range of 1 to 56 days. Approximately half (47%) of the errors occurred in patients undergoing treatment for leukemia or lymphoma, 28% for solid tumors, 17% for brain tumors, and 7% for non-malignant hematology patients. Ninety four (38%) errors were attributed to pharmacy, 83 (34%) to the providers, and 51 (20%) to the nurses. Seventy six (31%) were prescribing errors, 41 (16%) were administration errors, 31 (13%) were dispensing errors, and 26 (11%) were transcription errors. Approximately half (44%) of errors were of category B, an error occurred but did not reach the patient. Seventy six (31%) reports were category A, circumstances for error were present but no error occurred. Fifty nine (24%) were category C, an error reached the patient but caused no harm. Three errors reached the patient and could have contributed to harm (category D, F,G). Approximately one in three dispensing errors (32%), one in six prescribing errors (17%) and one in ten (11%) transcription errors reached the patient. Prescribing errors were the most common chemotherapy related errors in this study. One in four of all errors reached the patients. Errors occurred despite an institutional policy of two independent checks by providers, pharmacists, and nurses. More diligence is necessary on part of the person performing the second check on chemotherapy orders. Computerized provider order entry may help reduce chemotherapy related errors. Table1. Types of chemotherapy related errors Types of Errors N (%) Prescribing 76 (31) Delay 58 (23) Administration 41 (16) Dispensing 31 (13) Transcription 26 (11) Monitoring 7 (3) Compliance 4 (2) Omission 3 (1) Total 246 (100) Disclosures: No relevant conflicts of interest to declare.
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Sangwaiya, Minal Jagtiani, Shyla Saini, Michael A. Blake, Keith J. Dreyer, and Mannudeep K. Kalra. "Errare Humanum Est: Frequency of Laterality Errors in Radiology Reports." American Journal of Roentgenology 192, no. 5 (2009): W239—W244. http://dx.doi.org/10.2214/ajr.08.1778.

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Goodyear, Nancy, Bruce K. Ulness, Jennifer L. Prentice, Brad T. Cookson, and Ajit P. Limaye. "Systematic Assessment of Culture Review as a Tool to Assess Errors in the Clinical Microbiology Laboratory." Archives of Pathology & Laboratory Medicine 132, no. 11 (2008): 1792–95. http://dx.doi.org/10.5858/132.11.1792.

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Abstract Context.—Daily supervisory review is a common practice in microbiology laboratories; however, there are no publications describing errors corrected by this practice. Objective.—To determine (1) the correction rates for routinely reviewed positive cultures, (2) the correction rates for negative cultures, and (3) the types of corrections that are found, including the number with potential clinical significance. Design.—We prospectively assessed errors identified during culture report review for all positive (10-month period) and negative (1-month period) cultures at a single, university-based clinical microbiology laboratory in the United States. Errors were classified using predefined categories, and total and per category error rates were determined. A χ2 test was used to assess significant differences between error rates. Results.—A total of 112 108 culture reports were examined; 914 reports required a total of 1043 corrections. Of 101 703 positive culture reports, 786 (0.8%) required 900 corrections, 302 (0.3%) of which were potentially clinically significant. Of 10 405 negative culture reports, 128 (1.2%) required 143 corrections, 5 (0.05%) of which were potentially clinically significant. The rate of potentially clinically significant errors was significantly higher among positive versus negative culture reports (P < .001). Errors from positive culture reports most commonly involved susceptibility (374 [42%]), reporting (275 [31%]), and identification workup (217 [24%]). Most potentially significant errors from positive culture reports involved susceptibility testing (n = 253) and specimens from wound or lower respiratory tract (P < .001). Conclusions.—Review of culture reports from positive cultures from nonsterile sites with special attention to antimicrobial susceptibility testing and reporting would be most likely to detect potentially significant errors within the clinical microbiology laboratory.
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Burks, Jeffrey J. "Accounting Errors in Nonprofit Organizations." Accounting Horizons 29, no. 2 (2015): 341–61. http://dx.doi.org/10.2308/acch-51017.

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SYNOPSIS This study examines the accounting errors committed by public charities as revealed by searching for disclosures of their corrections in auditor reports, financial statements, and footnotes. A sample of 5,511 audited financial statements, predominantly from the years 2006 to 2010, was obtained from GuideStar, a data provider for nonprofits. Public charities report errors at a rate that is 60 percent higher than that of publicly traded corporations, and almost twice as high as that of similar-sized corporations. The errors are commonly errors of omission (i.e., failing to recognize items). The error rate has a strong positive association with internal control deficiencies and a strong negative association with Big 4 and second-tier auditors. Regressions are unable to detect a significant association between the error rate and organization size, type, or portion of the budget devoted to administrative activities. The error corrections often have low visibility in the financial reports issued by public charities; although they are reported in the footnotes of the audited financial statements, they often are not mentioned in auditor reports and in IRS Form 990s. The study improves our understanding of the accounting challenges faced by nonprofits, and may enhance nonprofit financial reporting by helping nonprofit managers and auditors understand the common circumstances and types of errors, and thus what activities to monitor more closely. The study also contributes to the academic literature by comparing the errors of nonprofits to those of corporations, by examining the outcomes of audits conducted by large as well as small auditors, and by advancing our understanding of discrepancies between audited and unaudited financial reports. Data Availability: Data are available from sources identified in the paper.
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Digumarthy, Subba Rao, Rachel Vining, Azadeh Tabari, et al. "Process improvement for reducing side discrepancies in radiology reports." Acta Radiologica Open 7, no. 7-8 (2018): 205846011879472. http://dx.doi.org/10.1177/2058460118794727.

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Background Laterality errors in radiology reports can lead to serious errors in management. Purpose To reduce errors related to side discrepancies in radiology reports from thoracic imaging by 50% over a six-month period with education and voice recognition software tools. Material and Methods All radiology reports at the Thoracic Imaging Division from the fourth quarter of 2016 were reviewed manually for presence of side discrepancies (baseline data). Side discrepancies were defined as a lack of consistency in side labeling of any abnormality in the “Findings” to “Impression” sections of the reports. Process map and Ishikawa fishbone diagram (Microsoft Visio) were created. All thoracic radiologists were educated on side-related errors in radiology reports for plan–design–study–act cycle 1 (PDSA #1). Two weeks later, voice recognition software was configured to capitalize sides (RIGHT and LEFT) in the reports during dictated (PDSA# 2). Radiology reports were analyzed to determine side-discrepancy errors following each PDSA cycle (post-interventional data). Statistical run charts were created using QI Macros statistical software. Results Baseline data revealed 33 side-discrepancy errors in 47,876 reports with an average of 2.5 errors per week (range = 1–8 errors). Following PDSA #1, there were seven errors pertaining to side discrepancies over a two-week period. Errors declined following implementation of PDSA #2 to meet the target of 0.85 side-discrepancy error per week over seven weeks. Conclusion Automated processes (such as capitalization of sides) help reduce left/right errors substantially without affecting reporting turnaround time.
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Dissertations / Theses on the topic "Reports of errors"

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Hong, Mei. "On two methods for identifying dynamic errors-in-variables systems." Licentiate thesis, Uppsala : Department of Information Technology, Uppsala University, 2005. http://www.it.uu.se/research/reports/lic/2005-007/.

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Ridelberg, Mikaela. "Towards safer care in Sweden? : Studies of influences on patient safety." Doctoral thesis, Linköpings universitet, Avdelningen för hälso- och sjukvårdsanalys, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-127307.

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Patient safety has progressed in 15 years from being a relatively insignificant issue to a position high on the agenda for health care providers, managers and policymakers as well as the general public. Sweden has seen increased national, regional and local patient safety efforts since 2011 when a new patient safety law was introduced and a four-year financial incentive plan was launched to encourage county councils to carry out specified measures and meet certain patient safety related criteria. However, little is known about what structures and processes contribute to improved patient safety outcomes and how the context influences the results. The overall aim of this thesis was to generate knowledge for improved understanding and explanation of influences on patient safety in the county councils in Sweden. To address this issue, five studies were con-ducted: interviews with nurses and infection control practitioners, surveys to patient safety officers and a document analysis of patient safety reports. Patient safety officers are healthcare professionals who hold key positions in their county council’s patient safety work. The findings from the studies were structured through a framework based on Donabedian’s triad (with a contextual element added) and applying a learning perspective, highlight areas that are potentially important to improve the patient safety in Swe-dish county councils. Study I showed that the conditions for the county councils’ patient safety work could be improved. Conducting root-cause analysis and attaining an organizational culture that encourages reporting and avoids blame were perceived to be of importance for improving patient safety. Study II showed that nurses perceived facilitators and barriers for improved pa-tient safety at several system levels. Study III revealed many different types of obstacles to effective surveillance of health care-associated infec-tions (HAIs), the majority belonging to the early stages of the surveillance process. Many of the obstacles described by the infection control practi-tioners restricted the use of results in efforts to reduce HAIs. Study IV of the Patient Safety Reports identified 14 different structure elements of patient safety work, 31 process elements and 23 outcome elements. These reports were perceived by patient safety officers to be useful for providing a structure for patient safety work in the county councils, for enhancing the focus on patient safety issues and for learning from the patient safety work that is undertaken. In Study V the patient safety officers rated efforts to reduce the use of antibiotics and improved communication be-tween health care practitioners and patients as most important for attaining current and future levels of patient safety in their county council. The patient safety officers also perceived that the most successful county councils regarding patient safety have good leadership support, a long-term commitment and a functional work organisation for patient safety work. Taken together, the five studies of this thesis demonstrate that patient safety is a multifaceted problem that requires multifaceted solutions. The findings point to an insufficient transition of assembled data and information into action and learning for improved patient safety.
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Domeniconi, Camila. "Auto-relato de erros em tarefas de leitura: efeitos de um treino de correspondência." Universidade Federal de São Carlos, 2006. https://repositorio.ufscar.br/handle/ufscar/2820.

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Made available in DSpace on 2016-06-02T19:43:59Z (GMT). No. of bitstreams: 1 TeseCD.pdf: 575295 bytes, checksum: 67693f4066c09400c8438c20419fa8ff (MD5) Previous issue date: 2006-03-06<br>Financiadora de Estudos e Projetos<br>When children with a history of school failure report on the outcomes of reading responses, most of them tend to report mostly correct responses, even after they make mistakes. This study investigated variables influencing correspondence in these reports and attempted to train correspondence to ensure accurate reports of errors, as well as of correct responses. Experimental sessions presented series of words on a computer screen. The computer dictated the correct word and children selected a green or a red window to report that the response had been correct or wrong. Baseline sessions showed that reports of errors as correct responses increased as a function of error probability. Training sessions then reinforced correspondence, providing points contingent to selections of the green window after a correct response and selections of the red window after an error. Correspondence quickly increased and was maintained in subsequent baseline sessions. Correspondence training was effective to establish accurate reports of errors in these children.<br>Quando crianças com história de fracasso escolar relatam seus resultados em leitura de palavras, a maioria delas tende a relatar a maior parte as respostas como corretas, mesmo que tenham cometido erros. Este estudo investigou as variáveis que influenciam a fidedignidade desses relatos e tentou treinar a correspondência para assegurar relatos correspondentes de erros, bem como de acertos. As sessões experimentais apresentaram diversas palavras em uma tela do computador. O computador ditou a palavra correta e as crianças selecionaram uma janela verde ou vermelha para relatar que a resposta tinha sido correta ou errada. As sessões da linha de base mostraram que os relatos de erros como respostas corretas aumentaram em função da probabilidade de erro. As sessões do treino reforçaram então a correspondência, fornecendo os pontos contingentes às seleções da janela verde após uma resposta correta e às seleções da janela vermelha após um erro. A correspondência aumentou rapidamente e foi mantida em sessões subsequentes de linha de base. O treinamento da correspondência foi eficaz para estabelecer relatos exatos dos erros nestas crianças.
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Koehn, Amy R. "To report or not report : a qualitative study of nurses' decisions in error reporting." Thesis, Indiana University, 2014. http://pqdtopen.proquest.com/#viewpdf?dispub=3665927.

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<p> This qualitative study was successful in utilization of grounded theory methodology to ascertain nurses' decision-making processes following their awareness of having made a medical error, as well as how and/or if they corrected and reported the error. Significant literature documents the existence of medical errors; however, this unique study interviewed thirty nurses from adult intensive care units seeking to discover through a detailed interview process their individual stories and experiences, which were then analyzed for common themes. Common themes led to the development of a theoretical model of thought processes regarding error reporting when nurses made an error. Within this theoretical model are multiple processes that outline a shared, time-orientated sequence of events nurses encounter before, during, and after an error. One common theme was the error occurred during a busy day when they had been doing something unfamiliar. Each nurse expressed personal anguish at the realization she had made an error, she sought to understand why the error happened and what corrective action was needed. Whether the error was reported on or told about depended on each unit's expectation and what needed to be done to protect the patient. If there was no perceived patient harm, errors were not reported. Even for reported errors, no one followed-up with the nurses in this study. Nurses were left on their own to reflect on what had happened and to consider what could be done to prevent error recurrence. The overall impact of the process of and the recovery from the error led to learning from the error that persisted throughout her nursing career. Findings from this study illuminate the unique viewpoint of licensed nurses' experiences with errors and have the potential to influence how the prevention of, notification about and resolution of errors are dealt with in the clinical setting. Further research is needed to answer multiple questions that will contribute to nursing knowledge about error reporting activities and the means to continue to improve error-reporting rates.</p>
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Harish, Kumar Rithika. "Spelling Correction To Improve Classification Of Technical Error Reports." Thesis, KTH, Skolan för elektroteknik och datavetenskap (EECS), 2019. http://urn.kb.se/resolve?urn=urn:nbn:se:kth:diva-263112.

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This master’s thesis project undertook the investigation of whether spelling correction would improve the performance of the classification of reports. The idea is to use different approaches of spelling correction to check which approach suits this particular dataset. Three different approaches were tested for spelling correction. The first two approaches considered only the erroneous word for correction. The third approach also considered context or the surrounding words to the erroneous word. The results after spelling correction were tested on a model classifier. No significant improvement in the performance of the classifier was observed when compared to the baseline. The reason for this might be because most of the reports do not contain more than a few spelling errors and the majority of words detected as spelling errors are not in English. However, the second approach performed better than the baseline for the dataset due to it being language independent as most of the non-words were non-english words which are dynamically updated based on input.<br>Det här examensarbetet undersökte huruvida stavningskontroll kan förbättra klassificering av rapporter. Tanken är att använda olika tillvägagångssätt för stavningskontroll för att finna det sätt som fungerar bäst på den här specifika datamängden. Tre olika tillvägagångssätt för stavningskontroll undersöktes. De två första tog bara hänsyn till enskilda felstavade ord. Det tredje sättet tog även hänsyn till det felstavade ordets kontext. Resultatet från stavningskontrollen testades på en klassificerare. Klassificeraren uppvisade inte någon signifikant förbättring vid jämförelse med en baslinje. Anledningen till detta kan vara att de flesta av rapporterna inte innehåller mer än några få stavfel och de flesta ord som upptäckts som stavfel är inte på engelska. Det andra tillvägagångssättet presterade dock bättre än baslinjen för datasetet tack vara att det var språkoberoende, eftersom de flesta av icke-orden var icke-engelska ord som dynamiskt uppdaterades baserat på input.
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Montague, Diane M. "Medication errors in hospitals : to ERR is human, to report is divine." Honors in the Major Thesis, University of Central Florida, 2001. http://digital.library.ucf.edu/cdm/ref/collection/ETH/id/235.

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This item is only available in print in the UCF Libraries. If this is your Honors Thesis, you can help us make it available online for use by researchers around the world by following the instructions on the distribution consent form at http://library.ucf.edu/Systems/DigitalInitiatives/DigitalCollections/InternetDistributionConsentAgreementForm.pdf You may also contact the project coordinator, Kerri Bottorff, at kerri.bottorff@ucf.edu for more information.<br>Bachelors<br>Health and Public Affairs<br>Legal Studies
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Schnoor, Jörg, Christina Rogalski, Roberto Frontini, Nils Engelmann, and Christoph-Eckhardt Heyde. "Case report of a medication error by look-alike packaging." Universitätsbibliothek Leipzig, 2015. http://nbn-resolving.de/urn:nbn:de:bsz:15-qucosa-162688.

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Background: The acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing patient safety are LASA as well as high workload. Case presentation: A critical incident report of medication errors of opioids for postoperative analgesia by lookalike packaging highlights the LASA aspects in everyday scenarios. A change to a generic brand of medication saved costs of up to 16% per annum. Consequently, confusion of medication incidents occurred due to the similar appearance of the newly introduced generic opioid. Due to consecutive underdosing no life-threatening situation arose out of this LASA based medication error. Conclusion: Current recommendations for the prevention of LASA are quite extensive; still, in a system with a lump sum payment per case not all of these security measures may be feasible. This issue remains to be approached on an individual basis, taking into consideration local set ups as well as financial issues.
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Panesar, Sukhmeet S. "Using a national repository of error reports to obtain insights into the safety of orthopaedic surgery." Thesis, University of Edinburgh, 2014. http://hdl.handle.net/1842/25051.

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Introduction: Almost a decade ago, there was a call to establish patient safety reporting systems that would operate at local, regional and national levels; it was envisaged that these would help healthcare professionals and organisations to learn from mistakes and lead to the development of interventions aimed at mitigating against these errors. This policy call led to the creation of the National Reporting and Learning System (NRLS). It however remains unclear whether reporting systems result in safer care. Specialties such as orthopaedics pose a high potential risk of iatrogenic harm, and this clinical area therefore represents a useful exemplar in which to study the opportunities offered by this national repository of errors to improve the safety of orthopaedic care provision. Aims: The aims of this thesis were to: • understand the opportunities offered by the NRLS to ascertain the frequency, types and causes of errors in orthopaedic surgery • develop the risk prediction potential of the system • offer critical reflections on the role of reporting systems for improving the care received by orthopaedic patients. Methods: Data on orthopaedic entries over the time period 2005-2008 were extracted from the National Patient Safety Agency's NRLS. Given the high volume of orthopaedic error reports, an approach was developed to prioritise areas most likely to result in patient harm. This approach was used to select four key areas, and examples of work undertaken to reduce the harm associated with orthopaedic surgery in these areas are presented. A detailed assessment of all orthopaedic deaths was also undertaken using an inductive approach of content analysis. A key aspect of this thesis was the creation of the Orthopaedic Error Index for hospitals, which allows a national assessment of the relative safety of provision of orthopaedic surgery. It uses existing principles of benchmarking to identify outlier hospitals where a large proportion of harm occurs compared to other hospitals. Results: There were 48,971 free-text reports of orthopaedic errors made available for analyses. These reports were grouped into 15 categories, which have been used since inception of the NRLS. A method of prioritising these categories of errors was developed which yielded an odds ratio of the most harmful category of errors compared to the others; these included errors associated with implementation of care and on-going monitoring/review [OR = 2.55 (95% CI 2.49, 2.62)]; self-harming behaviour [OR = 1.60 (95% CI 1.30, 1.96)]; infection control [OR= 1.50 (95% CI 1.41, 1.61)]; treatment, procedure [OR= 1.31 (95% CI 1.22, 1.42)]; and patient accidents [OR = 1.02 (95% CI 0.99, 1.05)]. In each of these error categories, where possible, topics were selected where there was a paucity of national guidelines on delivering safer orthopaedic care. All the deaths (n = 257) were also reviewed (2005-2009). Four main thematic categories emerged: (1) stages of the surgical journey - 62% of deaths occurred in the post-operative phase; (2) causes of patient death - 32% were related to severe infections; (3) reported quality of medical interventions - 65% of patients experienced minimal or delayed treatment; and (4) skills of healthcare professionals - 44% of deaths had a failure in non-technical skills. A single error could have multiple themes, hence all errors did not add up to 100%. National alerts were then produced to mitigate risks associated with the use of digital tourniquets, hip cement, and slips, trips and falls. Data from 155 hospitals were used to create an Orthopaedic Error Index (OEI) which was normally distributed. The mean OEI was 7.09/year (SD 2.72); five hospitals were identified as outliers, lying three standard deviations above the mean OEI. This is the first time that a direct measure of patient safety has been created and used. Discussion: Reporting systems such as the NRLS offer a potentially important approach for orthopaedic surgeons to better understand the safety considerations of their work. This work has shown that content analyses and prioritisation of errors can be beneficial for large databases and can alert orthopaedic surgeons to practices of unsafe care. Subsequent solutions to mitigate against these errors can furthermore be developed. It is also possible to use the NRLS for risk prediction and identify, earlier on, any hospitals that have significant variation in the severity and propensity of errors. It is hoped that this work will catalyse efforts by a few in orthopaedic surgery to recognise that unsafe care is a problem and needs to be better understood and appropriate solutions developed.
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Brigham, Leeann. "Analysis of Report Addenda as a Novel Approach to Characterization and Quantification of Errors in Diagnostic Radiology." Thesis, Harvard University, 2015. http://nrs.harvard.edu/urn-3:HUL.InstRepos:17295902.

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Diagnostic errors are common in radiology and can have a significant negative impact on patient care. Identifying the types of errors that occur can improve our understanding of the root causes and suggest pathways for improvement. To date, studies have focused on errors occurring in difficult cases, which have higher error rates but are not representative of the errors occurring in hospitals on a daily basis. In most hospitals, radiologists attach addenda to reports when an error needs correction. Therefore, addenda are markers for errors and provide a more complete, non-biased picture that may be more relevant to improving outcomes. Using report addenda at a large university hospital we analyzed the types of errors in 1,195 cases and found that radiology studies at our hospital have an error rate of 0.9%. Our results demonstrate that in daily radiology practice, errors of poor communication occur most frequently (36%), followed by under-reading (23%), procedure-related (20%), insufficient history (15%), over-reading (5%), and poor technique (0.5%). When analyzed by modality, most errors occurred in interventional procedures, followed by PET, MRI, and CT. Errors of communication are often preventable and suggest a clear area for intervention. More broadly, our success using addenda to study clinical errors demonstrates the feasibility of this novel approach, which would be reproducible at virtually all institutions.
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Pina-Sánchez, Jose. "Prevalence, impact, and adjustments of measurement error in retrospective reports of unemployment : an analysis using Swedish administrative data." Thesis, University of Manchester, 2014. https://www.research.manchester.ac.uk/portal/en/theses/prevalence-impact-and-adjustments-of-measurement-error-in-retrospective-reports-of-unemployment-an-analysis-using-swedish-administrative-data(74e7e851-d89b-4b91-830e-410a06fb6fde).html.

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In this thesis I carry out an encompassing analysis of the problem of measurement error in retrospectively collected work histories using data from the “Longitudinal Study of the Unemployed”. This dataset has the unique feature of linking survey responses to a retrospective question on work status to administrative data from the Swedish Register of Unemployment. Under the assumption that the register data is a gold standard I explore three research questions: i) what is the prevalence of and the reasons for measurement error in retrospective reports of unemployment; ii) what are the consequences of using such survey data subject to measurement error in event history analysis; and iii) what are the most effective statistical methods to adjust for such measurement error. Regarding the first question I find substantial measurement error in retrospective reports of unemployment, e.g. only 54% of the subjects studied managed to report the correct number of spells of unemployment experienced in the year prior to the interview. Some reasons behind this problem are clear, e.g. the longer the recall period the higher the prevalence of measurement error. However, some others depend on how measurement error is defined, e.g. women were associated with a higher probability of misclassifying spells of unemployment but not with misdating them. To answer the second question I compare different event history models using duration data from the survey and the register as their response variable. Here I find that the impact of measurement error is very large, attenuating regression estimates by about 90% of their true value, and this impact is fairly consistent regardless of the type of event history model used. In the third part of the analysis I implement different adjustment methods and compare their effectiveness. Here I note how standard methods based on strong assumptions such as SIMEX or Regression Calibration are incapable of dealing with the complexity of the measurement process under analysis. More positive results are obtained through the implementation of ad hoc Bayesian adjustments capable of accounting for the different patterns of measurement error using a mixture model.
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Books on the topic "Reports of errors"

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Raine, Joseph E. Avoiding errors in paediatrics. Wiley-Blackwell, 2013.

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Barbara, Krug Kathrin, ed. Avoiding errors in radiology: Case-based analysis of causes and preventive strategies. Thieme, 2011.

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Seegmiller, Adam C. Hematology and immunology: Quality in laboratory diagnosis. Demos Medical Publishing, 2014.

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A, Nguyen Dung, ed. Learning from medical errors: Clinical problems. Radcliffe Pub., 2005.

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A, Nguyen Dung, ed. Learning from medical errors: Legal issues. Radcliffe, 2005.

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Cardosi, Kim M. Pilot-controller communication errors: An analysis of Aviation Safety Reporting System (ASRS) reports. Federal Aviation Administration, Office of Aviation Research, 1999.

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Cardosi, Kim M. Pilot-controller communication errors: An analysis of Aviation Safety Reporting System (ASRS) reports. U.S. Dept. of Transportation, Federal Aviation Administration, Office of Aviation Research, 1998.

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Cardosi, Kim M. Pilot-controller communication errors: An analysis of Aviation Safety Reporting System (ASRS) reports. U.S. Dept. of Transportation, Federal Aviation Administration, Office of Aviation Research, 1998.

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Muller, René J. Doing Psychiatry Wrong. Taylor and Francis, 2007.

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Doing psychiatry wrong: A critical and prescriptive look at a faltering profession. Analytic Press, 2008.

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Book chapters on the topic "Reports of errors"

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Alfadhel, Majid, Muhammad Talal Alrifai, Daniel Trujillano, et al. "Asparagine Synthetase Deficiency: New Inborn Errors of Metabolism." In JIMD Reports. Springer Berlin Heidelberg, 2015. http://dx.doi.org/10.1007/8904_2014_405.

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Sirrs, S. M., H. Faghfoury, E. M. Yoshida, and T. Geberhiwot. "Barriers to Transplantation in Adults with Inborn Errors of Metabolism." In JIMD Reports. Springer Berlin Heidelberg, 2012. http://dx.doi.org/10.1007/8904_2012_171.

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Shi, Xiao-Tong, Juan Cai, Yuan-Yu Wang, et al. "Newborn Screening for Inborn Errors of Metabolism in Mainland China: 30 Years of Experience." In JIMD Reports. Springer Berlin Heidelberg, 2012. http://dx.doi.org/10.1007/8904_2011_119.

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Wallevik, Jon Elvar, Knut Krenzer, and Jörg-Henry Schwabe. "Numerical Errors in CFD and DEM Modeling." In RILEM State-of-the-Art Reports. Springer Netherlands, 2014. http://dx.doi.org/10.1007/978-94-017-8884-7_4.

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Aygen, Sitke, Ulrich Dürr, Peter Hegele, et al. "NMR-Based Screening for Inborn Errors of Metabolism: Initial Results from a Study on Turkish Neonates." In JIMD Reports. Springer Berlin Heidelberg, 2014. http://dx.doi.org/10.1007/8904_2014_326.

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Al-Jasmi, Fatma A., Aisha Al-Shamsi, Jozef L. Hertecant, Sania M. Al-Hamad, and Abdul-Kader Souid. "Inborn Errors of Metabolism in the United Arab Emirates: Disorders Detected by Newborn Screening (2011–2014)." In JIMD Reports. Springer Berlin Heidelberg, 2015. http://dx.doi.org/10.1007/8904_2015_512.

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Zeltner, Nina A., Markus A. Landolt, Matthias R. Baumgartner, et al. "Living with Intoxication-Type Inborn Errors of Metabolism: A Qualitative Analysis of Interviews with Paediatric Patients and Their Parents." In JIMD Reports. Springer Berlin Heidelberg, 2016. http://dx.doi.org/10.1007/8904_2016_545.

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Sirrs, S., C. Hollak, M. Merkel, et al. "The Frequencies of Different Inborn Errors of Metabolism in Adult Metabolic Centres: Report from the SSIEM Adult Metabolic Physicians Group." In JIMD Reports. Springer Berlin Heidelberg, 2015. http://dx.doi.org/10.1007/8904_2015_435.

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Schaeffer, Nora Cate. "Errors of Experience: Response Errors in Reports about Child Support and Their Implications for Questionnaire Design." In Autobiographical Memory and the Validity of Retrospective Reports. Springer New York, 1994. http://dx.doi.org/10.1007/978-1-4612-2624-6_10.

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Zeltner, Nina A., Matthias R. Baumgartner, Aljona Bondarenko, et al. "Development and Psychometric Evaluation of the MetabQoL 1.0: A Quality of Life Questionnaire for Paediatric Patients with Intoxication-Type Inborn Errors of Metabolism." In JIMD Reports. Springer Berlin Heidelberg, 2017. http://dx.doi.org/10.1007/8904_2017_11.

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Conference papers on the topic "Reports of errors"

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Barr, Matthew, Sam Holden, Dave Phillips, and Tony Greening. "An exploration of novice programming errors in an object-oriented environment." In Working group reports from ITiCSE. ACM Press, 1999. http://dx.doi.org/10.1145/349316.349392.

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Whitney, Paul, Jonathan Young, John Santell, Rodney Hicks, Christian Posse, and Barbara Fecht. "Analysis of Medication Error Reports." In ASME 2004 International Mechanical Engineering Congress and Exposition. ASMEDC, 2004. http://dx.doi.org/10.1115/imece2004-61182.

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In medicine, as in many areas of research and society, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been a corresponding lag in our abilities to analyze this mass of data, and traditional forms and expressions of statistical analysis do not allow researchers and practitioners to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports are approached as data comparisons, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Additionally, the “types” of information objects that can be the objects of data analysis have been extended to include text [8][9]. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. USP conducts an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.
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Mende, Jens. "Modular Inference Trees for Expository Reports." In InSITE 2005: Informing Science + IT Education Conference. Informing Science Institute, 2005. http://dx.doi.org/10.28945/2933.

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When people write a report that involves a complex argument towards a conclusion, they can use a design tool called the inference tree, which enables them to outline the argument, and quickly detect reasoning errors in the outline. Yet when the argument is very complex, the inference tree may spread over several pages, so that writers may often have to flip back and forth between those pages. To prevent unnecessary flipping, they can draw the tree as a hierarchy of modules, similar to a modular hierarchy of program flowcharts or structure charts, where a major module controls several minor modules. In drawing the tree, writers can adopt four principles of Computing: modularity, the criterion of minimal coupling between modules, and the methods of forward and backward chaining to draw all the modules.
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Hoffmann, Nadine, and Ulrike Kuhlmann. "Design of steel and composite structures for robustness." In IABSE Workshop, Helsinki 2017: Ignorance, Uncertainty, and Human Errors in Structural Engineering. International Association for Bridge and Structural Engineering (IABSE), 2017. http://dx.doi.org/10.2749/helsinki.2017.118.

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The paper briefly reports on investigations concerning the robustness of steel and composite structures. When applying the alternate load path method for redistributing the loads resulting from a column loss especially the detailed consideration of the behaviour of beam‐to‐column joints is important. A crucial aspect is the investigation of the available rotation capacity of the joints as well as the required rotation capacity of the joints. Finally a method is presented that can be used in order to verify the rotation capacity for permanent load situation as well as for accidental load situations.
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Palmero, D., ER Di Paolo, C. Stadelmann, A. Pannatier, JF Tolsa, and F. Sadeghipour. "5PSQ-154 Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns." In 24th EAHP Congress, 27th–29th March 2019, Barcelona, Spain. British Medical Journal Publishing Group, 2019. http://dx.doi.org/10.1136/ejhpharm-2019-eahpconf.587.

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Sawhney, Rapinder, Harshitha Muppaneni, Gewei Zhang, and Hongbiao Yang. "Natural Interaction: A Mechanism for Mistake Proofing Operator’s Errors on Trains." In 2013 Joint Rail Conference. American Society of Mechanical Engineers, 2013. http://dx.doi.org/10.1115/jrc2013-2448.

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Railroad accidents are not only very expensive but also fatal. National Transportation safety data from 2000–2011 indicate staggering numbers — a total of 141 fatalities and 5118 injuries. Filtering Board’s reports on train accidents in last decade point to 28% of fatalities classified as the driver’s fault. The reports also provide that accidents occurring due to operators’ failure amount to a total of $162 million dollars in revenue loss. Most of the accidents caused by operators occur due to miss communication and less response time along with lack of judgment during a crisis situation. Parameters such as Fatigue, reflexes and alertness can be based on many ergonomic factors. Projecting the path of action in advance can assist operators to recognize calamity ahead and prevent them. Software that can enable operators to get trained in a virtual environment with actual control operations in place would be perfect alternative to prepare them for crisis situation in real world. Available train simulator software represents realistic view of operator cab and allows Operators to recreate conditions similar to that encountered in real world. Current work is aimed at enhancing such software with options that can enable operator to integrate alerts, speed changes along the route and have up-to-date traffic information, signal situations and schedule breaks and assists them to act in consequence and function more efficiently to handle crucial situations. This software can also display information, such as operators own position, and relay systems alerts more efficiently, which eliminates miss-communication of operator and control center due to lack of proper radio signals. This enhancement would act as a natural interaction system which is more specific alternative and effective tool for operators with real time data at their fingertips and act as a support system to enable them make fast and accurate decisions. Implementing this software into present systems, can enable better safety through raising operator awareness under tough environment and enhance their safety, resulting in saving loss of revenue along with reduced fatality rates.
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Armstrong, C. G., T. K. H. Tam, D. J. Robinson, R. M. McKeag, and M. A. Price. "Automatic Generation of Well Structured Meshes Using Medial Axis and Surface Subdivision." In ASME 1991 Design Technical Conferences. American Society of Mechanical Engineers, 1991. http://dx.doi.org/10.1115/detc1991-0114.

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Abstract This paper reports on a project in which automatic mesh generation is divided into two phases. In the first phase feature recognition and shape grammar techniques, based on the medial axis of a 2D region, are employed to decompose a complex component into a number of simple subregions. In the second phase the subregions are meshed to a controlled density using conventional mapped mesh methods. The advantage of this approach is that good quality meshes of quadrilateral elements can be generated in 2D and, potentially, meshes of hexahedral elements in 3D. A parallel program of work has concentrated on the analysis of errors: different methods for error estimation and for providing transitions in mesh density have been compared.
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Cheesewright, Robert, and Colin Clark. "Experimental Investigation of the Influence of External Vibrations on Coriolis Mass Flow Meters." In ASME 2002 International Mechanical Engineering Congress and Exposition. ASMEDC, 2002. http://dx.doi.org/10.1115/imece2002-32210.

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The Coriolis flow meter is basically a vibrating tube device; it is therefore potentially susceptible to disruption by external vibrations transmitted from the environment in which the meter is mounted. The paper reports the findings from a carefully structured experimental study in which the results of both analysis and numerical simulation studies were used to guide the choice of vibration frequencies and the directions and the spatial distributions of the vibrations. The total of eight different meters from five different manufacturers covered a wide range of meter geometries and drive frequencies. In addition to comparisons of the flow rates indicated by the meters with independent measures of the flow rate, all the tests involved the recording of raw signals from the displacement sensors so that the effects of using different techniques to extract the phase relationship between these signals could be investigated. All the tests were performed using cold (room temperature) water as the working fluid. The results of the study show that vibrations at the meter drive frequency caused errors in all meters. Vibrations at other frequencies also caused errors in several meters but these errors appear to be due to the algorithm (implemented in the meter electronics) used to extract the phase difference (the measurand) between the sensor signals. However, the complete study suggests that, by suitable choices of meter mechanical design and of the algorithm used to determine the phase difference, it is possible to make a meter which is unaffected by vibrations at any frequency other than the meter drive frequency (provided only that the meter tube motion produced by the vibration is smaller than that produced by the meter drive). For vibrations at the drive frequency the results show that (in general agreement with the analytical and numerical studies) the magnitude of the error depends on the phase relationship between the imposed vibration and the meter drive. Errors also depend on the spatial distribution of the vibration (e.g. the error is different for the same amplitude of vibration applied uniformly to a meter and applied to one end only of the meter). Methods for reducing drive frequency errors are discussed but it is concluded that it may not be possible to eliminate these errors completely.
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Hockaday, Bruce D. "Quantifying Optical Tip-Timing Probe Error With Laboratory Apparatus." In ASME 2011 Turbo Expo: Turbine Technical Conference and Exposition. ASMEDC, 2011. http://dx.doi.org/10.1115/gt2011-46677.

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Detection of airfoil time of arrival with optical probes has been evolving since the 1980s. Time of arrival data are used to infer airfoil stresses caused by vibration through a sequence of manipulations. The data conversion begins by converting arrival time to blade position, so blade deflection can be determined from the expected non-vibrating position. Various methods are used in the industry to convert deflection data to frequency, amplitude, and stress, which is beyond the scope of this paper. Regardless of the analytical approach used, producing accurate stress information relies on the precise detection and measurement of time of arrival, which equates to blade position. Recent improvements have been made in time of arrival system accuracy by running faster clocks to increase temporal resolution of the measurement. Greater timing resolution, afforded by clock speed, will have diminishing returns when probe and blade-tip interactions begin producing dominant errors. In the case of optical probes, the blade-tip needs to be treated as a curved reflector in the optical system that is capable of introducing dynamic errors. In engine operation the blade-tip moves axially under the probe from untwist, static deflection, and vibration, causing the light to reflect from different parts of the blade-tip. This relative movement between the probe and blade-tip cause the arrival time to change dynamically. Neglecting the dynamic arrival errors caused by the blade-tip’s optical properties will result in blade deflection-errors that propagate into the stress information. This paper presents a laboratory study that quantifies time of arrival errors due to optical interaction with tip radii. The study reports measured arrival position error as a function of location and optical signal power levels. The work is presented in terms of arrival position, producing information that is independent of rotational speed, and vibratory mode.
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Montes, Edward Francisco Oliveros. "Unprovoked Errors in Geotechnical Monitoring Activities in an RoW." In ASME 2015 International Pipeline Geotechnical Conference. American Society of Mechanical Engineers, 2015. http://dx.doi.org/10.1115/ipg2015-8518.

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The Camisea Pipeline Transmission System (PTS), owned by Transportadora de Gas del Perú (TgP) in Peru, consists of two parallel pipelines, a Natural Gas (NG) pipeline and a Liquefied Natural Gas (LNG) pipeline. The NG pipeline is 834 km in length, including a 105 km loop. The LNG pipeline is 557 km in length. The first 210 km, are defined as having Amazonian geotechnical characteristics, with the presence of sedimentary and metamorphic rocks and a deposit of materials that are easily altered, which are associated with the transition between the Amazon plain and the Andes mountains. The area between km 210 and km 420 is defined as a mountainous sector with materials having better mechanical properties while the section between km 420 and km 730 located in the coastal sector and has erosive processes such as those associated with wind erosion, seismic activity, alluvial deposits, etc. Due to the variety of geological and geotechnical circumstances of the TgP’s RoW, its PTS incorporates many types of geotechnical monitoring in order to maintain and increase the reliability and integrity of the system. In several sectors not all of the types of monitoring are applicable. Some types of monitoring are: inclinometers and piezometers, aerial surveillance, patrolling, strain gauges (SG), topographic, GIS images (satellite, laser, radar, etc.), culverts, geotechnical optical fiber, accelerometer stations, etc. This article describes some unprovoked errors that can occur in a complex operation (in terms of logistics, geological, geotechnical and socially), in the development of geotechnical monitoring activities of an RoW. Some of the errors that can occur are: • Unacceptable photographic record through aerial surveillance; • Damage to the coating during topographic verification; • Field reports with incorrect data; • Incorrect SG records; • Improper placement of equipment over the pipeline; • Incorrect records in the GIS database; • Errors in the topographical record; and • Inexperience of monitoring staff, etc. However, occurrence of the above-mentioned errors has been lessened through improved operating procedures. These procedures are based on discussions from the various “lessons learned” sessions, which improved: • the appropriate recording of conditions identified in the field; • the labor climate; • crosswise communication between the different areas; and • the preventive approach within the operation of the PTS.
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Reports on the topic "Reports of errors"

1

Schumacher, R. F. Errors of DWPF Frit analysis. Final report. Office of Scientific and Technical Information (OSTI), 1992. http://dx.doi.org/10.2172/10104486.

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Schumacher, R. F. Errors of DWPF frit analysis: Final report. Office of Scientific and Technical Information (OSTI), 1993. http://dx.doi.org/10.2172/6645420.

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Schumacher, R. F. Errors of DWPF frit analysis: Final report. Revision 1. Office of Scientific and Technical Information (OSTI), 1993. http://dx.doi.org/10.2172/10138758.

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Stevens, Susan M., M. Victoria Ramos, Caren A. Wenner, and Nathan Gregory Brannon. Human error mitigation initiative (HEMI) : summary report. Office of Scientific and Technical Information (OSTI), 2004. http://dx.doi.org/10.2172/920113.

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Stock, D. A., D. A. Shurberg, and J. N. O`Brien. Analysis of personnel error occurrence reports across Defense Program facilities. Office of Scientific and Technical Information (OSTI), 1994. http://dx.doi.org/10.2172/10181613.

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Edwards, T. B. Estimation of Total Error in DWPF Reported Radionuclide Inventories. Office of Scientific and Technical Information (OSTI), 1995. http://dx.doi.org/10.2172/64815.

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An, Yonghong, and Yingyao Hu. Well-posedness of measurement error models for self-reported data. Institute for Fiscal Studies, 2009. http://dx.doi.org/10.1920/wp.cem.2009.3509.

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Carbin, Michael, and Saman Amarasinghe. AEDAM: Whole Program Adaptive Error Detection and Mitigation—Year 3 Report. Office of Scientific and Technical Information (OSTI), 2019. http://dx.doi.org/10.2172/1499251.

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Brill, Eric. A Report of Recent Progress in Transformation-Based Error-Driven Learning. Defense Technical Information Center, 1994. http://dx.doi.org/10.21236/ada460636.

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Majda, Andrew J. Report: Low Frequency Predictive Skill Despite Structural Instability and Model Error. Defense Technical Information Center, 2013. http://dx.doi.org/10.21236/ada601429.

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