Awareness Of Errors Research Articles

Attention and Arousal in Neurorehabilitation

Event Abstract Back to Event Attention and Arousal in Neurorehabilitation Ian Robertson1* 1 Trinity College Dublin, Ireland The experience-dependent plastic changes in the primate sensory cortex observed after repeated sensory stimulation do not occur, or are greatly reduced, if the animal’s attention is not directed to the sensory stimulation, but rather is distracted by rewards in another sensory modality. Attention’s role in ‘gating’ experience-dependent plasticity in the human brain is also modulated by levels of arousal, reflected in particular in the norepinephrine system of the brain. Arousal and attention – in particular sustained attention – have strong roles in mediating awareness of error and of impairment; many studies have shown that neurorehabilitation effectiveness is grossly diminished in patients who have an impaired ‘insight’ into their deficits. These three factors – sustained attention, arousal and awareness, all have a very strong linkage to a right hemisphere fronto-parietal parietal attention system which reveals itself to be amenable to plastic, training-related changes. This paper presents data from a number of experimental studies with attention deficit disorder and normal aging, and presents data from a single blind randomized controlled trial of working memory training with an elderly population showing training effects that generalize to a task known to depend on the right fronto-parietal system in question.

Health Literacy and Children: Introduction

In the setting of increased interest in health literacy, the American Academy of Pediatrics (AAP) convened a national conference on health literacy and pediatrics in Washington, DC, on November 8, 2008: “A Health-Literate America: Where Do Children Fit In?” The purpose of the conference was to examine health literacy related issues, problems, and opportunities with reference to children and children's health. Most health literacy research and interventions have focused on adult patients and diagnoses, and this gathering—which brought together pediatricians, health literacy researchers, educators, health systems researchers and policy makers, and adult learners—was designed to address complex questions related to where children fit in a national health literacy agenda. Themes of the conference that run through this collection of commissioned articles, which were presented at the conference and are published in this supplement to Pediatrics , identify some of the ways in which children are distinct from adults regarding issues of health literacy while reminding us of how they are also part of the larger health literacy picture. The challenge of including children in a “health-literate America” is necessarily part of the overall challenge of addressing health literacy. The goals for children and their adult caregivers are the same as for adults: to use the health literacy perspective and its insights and evidence base to enhance the health care system, increase access and inclusion, reduce disparities, and improve health outcomes. This supplement to Pediatrics includes a systematic review by DeWalt and Hink1 of the literature on health literacy and child health outcomes, including analysis of methodology, discussion of the parent-child dyad, and opportunities for studying new interventions as they are developed. Wolf et al,2 in their article, observe the relationship between health literacy and health learning, offer a broadened definition of health literacy, and emphasize … Address correspondence to Benard P. Dreyer, MD, New York University School of Medicine, Department of Pediatrics, 550 First Ave, NBV 8S4-11, New York, NY 10016. E-mail: bpd1{at}nyu.edu

Analysing the “field” of patient safety employing Bourdieusian technologies

This paper aims to analyse the development of patient safety as a field within which patients are peripheral stakeholders. The authors examined the patient safety movement from the perspective of a field in which agents struggle for control over various forms of capital, including economic, social, cultural and symbolic capital. In order to undertake this analysis the authors drew on the literature on errors and patient safety, key inquiries into patient safety, and research conducted with health professionals in New South Wales, Australia. The patient safety movement has created a heightened sense of awareness of errors and risk across health systems, thereby attracting and creating significant amounts of capital. The authors argue that in the process of struggle to constitute and contain a new field of health, patients and their narratives are rendered vulnerable to appropriation and incorporation. By considering patient safety from a sociological rather than a technical framework, it is possible to gain new insights into why reducing the levels of medical errors have proven so difficult. Improved knowledge of how patient safety operates as a field may contribute to more effective strategies in reducing those types of errors. Despite the growth in the number of publications in patient safety there has been only minimal analysis of the field itself, rather than its technical or organisational components. This paper contributes to a new way of conceptualising and enacting patient safety, one that acknowledges the vulnerability of the parties involved, particularly patients.

Pediatricians and Health Literacy: Descriptive Results From a National Survey

To describe pediatricians' self-reported experiences with health literacy, use of basic and enhanced communication techniques, and perceived barriers to effective communication during office visits. A national, random sample of 1605 nonretired, posttraining American Academy of Pediatrics members were surveyed in 2007 about health literacy and patient communication as part of the Periodic Survey of Fellows. The response rate was 56% (N = 900). Eight-one percent of the pediatricians were aware of a situation in the previous 12 months in which a parent had not sufficiently understood health information that had been delivered to him or her. In addition, 44% of all pediatricians were aware of a communication-related error in patient care within the previous 12 months. Using simple language (99%), repeating key information (92%), and presenting only 2 or 3 concepts at a time (76%) were the most commonly used communication strategies. Enhanced communication techniques recommended by health literacy experts such as teach-back and indicating key points on written educational materials were used less often (23% and 28%, respectively). The most common reported barriers to effective communication were limited time to discuss information (73%), volume of information (65%), and complexity of information (64%). The majority of physicians rated themselves highly in their ability to identify caregiver understanding (64%), but only 21% rated themselves as very good or excellent in identifying a parent with a literacy problem. Fifty-seven percent of the respondents were interested in training to improve communication skills, and 58% reported that they would be very likely to use easy-to-read written materials, if available from the American Academy of Pediatrics. Pediatricians are aware of health literacy-related problems and the need for good communication with families but struggle with time demands to implement these skills. Despite awareness of communication-related errors in patient care, pediatricians report underutilizing enhanced techniques known to improve communication.

Laboratory Session to Improve First-year Pharmacy Students' Knowledge and Confidence Concerning the Prevention of Medication Errors

To implement a laboratory session into the first-year pharmacy curriculum that would provide active-learning experiences in the recognition, resolution, and prevention of medication errors. Students participated in medication error-prone prescription processing and counseling simulations, role-played communication strategies after a medication error occurred, and discussed an introductory pharmacy practice experience focused on prescription processing and prevention of medication errors. Students completed an assessment prior to and after completion of the laboratory on their knowledge of and confidence in identifying medication errors. Students' knowledge and awareness of medication errors improved as did confidence in their ability to (1) recognize and avoid errors, (2) utilize methods to prevent errors, (3) communicate about errors with involved parties, and (4) select and report medication errors on an appropriate form. Students' awareness of the pharmacist's role in medication error reduction improved and confidence in their ability to recognize, prevent, and communicate medication errors increased.

Assessment of specialists in cardiovascular practice

Assessment of medical specialists was introduced to ensure patient safety and to maintain professional knowledge. Cardiovascular specialist assessment is challenging, as the ongoing development of new technologies is associated with increased requirements for up-to-date training and acquisition of new skills. The cardiovascular specialties include cardiology, vascular interventional radiology, cardiac surgery and vascular surgery. Assessment within these disciplines involves evaluation of knowledge in addition to technical and nontechnical skills, a process that is termed recertification or maintenance of certification. Increasingly, there is a demand for professional accountability through recertification because of concerns about professional negligence and increased awareness of medical errors. In this article we describe the process of recertification in different geographical regions and discuss the role of current tools used to recertify cardiovascular specialists and, in particular, how their use can contribute to the requirements of patient care.

Phonological awareness and types of sound errors in preschoolers with speech sound disorders.

Some children with speech sound disorders (SSD) have difficulty with literacy-related skills, particularly phonological awareness (PA). This study investigates the PA skills of preschoolers with SSD by using a regression model to evaluate the degree to which PA can be concurrently predicted by types of speech sound errors. Preschoolers with SSD (n = 43) participated in PA and speech sound production assessment. Errors from a 125-item picture naming task were coded in 2 ways: (a) considering all consonant errors equally (percentage of consonants correct [PCC]) and (b) using a 3-category system that captures component features of sound errors (typical sound changes, atypical sound changes, and distortions). PA tasks included rhyme matching, onset matching, onset segmentation and matching, and blending. Variance in a PA composite score could be predicted partly by vocabulary and age (33%). Atypical sound changes accounted for an additional 6% of variance in PA, but distortions and typical errors did not account for significant variance. When the same consonant errors were analyzed using PCC, speech errors did not predict significant variance in PA. Poorer PA is associated with lower receptive vocabularies and more atypical sound errors. Results are interpreted in the context of the accuracy of phonological representations.

Impaired Error Awareness and Anterior Cingulate Cortex Hypoactivity in Chronic Cannabis Users

Drug abuse and other psychiatric conditions (e.g., schizophrenia) have been associated with a diminished neural response to errors, particularly in the anterior cingulate cortex (ACC) thought critical to error processing. A diminished capacity for detecting errors has been linked to clinical symptoms including the loss of insight, delusions and perseverative behaviour. Sixteen active chronic cannabis users and 16 control participants were administered a Go/No-go response inhibition task during event-related fMRI data collection. The task provides measures of inhibitory control and error awareness. Cannabis users’ inhibitory control performance was equivalent to that of the control group, but the former demonstrated a significant deficit in awareness of commission errors. Cannabis users demonstrated a diminished capacity for monitoring their behaviour that was associated with hypoactivity in the ACC and right insula. In addition, increased levels of hypoactivity in both the ACC and right insula regions were significantly correlated with error awareness rates in the cannabis group (but not controls). These difficulties are consistent with previous reports of hypoactivity in the neural systems underlying cognitive control and the monitoring of interoceptive awareness in chronic drug users, and highlight the potential relationship between cognitive dysfunction and behavioural deficits that have the potential to contribute to the maintenance of drug abuse.

A computational model for evaluating the effects of attention, memory, and mental models on situation assessment of nuclear power plant operators

Operators in nuclear power plants have to acquire information from human system interfaces (HSIs) and the environment in order to create, update, and confirm their understanding of a plant state, as failures of situation assessment may cause wrong decisions for process control and finally errors of commission in nuclear power plants. A few computational models that can be used to predict and quantify the situation awareness of operators have been suggested. However, these models do not sufficiently consider human characteristics for nuclear power plant operators. In this paper, we propose a computational model for situation assessment of nuclear power plant operators using a Bayesian network. This model incorporates human factors significantly affecting operators’ situation assessment, such as attention, working memory decay, and mental model. As this proposed model provides quantitative results of situation assessment and diagnostic performance, we expect that this model can be used in the design and evaluation of human system interfaces as well as the prediction of situation awareness errors in the human reliability analysis.

Improving Medication Error Reporting in Hospice Care

The aims of this study are to determine the incidence of medication errors, characterize the type/severity of errors, and estimate the impact of an educational intervention on medication error processes in a hospice population. Medication errors from 2 hospice organizations were collected and coded for type of error/outcome severity. The educational intervention included a 2-hour in-service and twice weekly reminders. A survey to assess participants' change in knowledge and attitudes regarding medication error reporting through the study period and was administered at 3 different time points. Data analysis revealed that medication error reporting increased in one hospice program, that participants' ability to correctly identify medication errors increased (P < .001), and awareness of medication errors in hospice care increased (P < .01) after the intervention.

Medical Errors Education for Students of Surgery: A Pilot Study Revealing the Need for Action

Medical errors training is an important yet often overlooked aspect of surgical education. In response to a perceived deficiency in medical errors training at our institution, we implemented an educational session on medical errors concepts for the benefit of rotating medical students. Medical students completed the same 12-question test before and after the 90-minute educational session. Pretest and posttest scores were compared for evidence of enhanced understanding. No personal identifiers were used, and students were provided unlimited time to complete the tests. Six groups of medical students (who ranged from 5 to 8 students per session) completed the educational session. All sessions were moderated by the same surgical resident and attending surgeon, who used a standard slide presentation. Test scores were analyzed with SPSS statistical software (version 14.0; SPSS Inc., Cary, NC), which employed the paired samples t-test (alpha = 0.05). Test scores increased significantly from a pretest mean of 27.3% correct (3.28 of 12 possible, SD = 1.57) to a mean posttest score of 70.1% (8.41, SD = 1.52) (p < 0.001). This retrospective pilot study demonstrated that a brief educational intervention led to statistically significant improved performance on a general understanding of medical errors. The study also revealed the dearth of baseline knowledge in our participating medical students on the subject. We believe that these results underscore the need for action in providing improved and ongoing education in medical errors concepts to enhance medical student awareness and proactive handling of medical errors.

Electrical brain events associated with awareness of errors

Objective: The neurophysiological correlates of mental activity and awareness are important to define, as they permit the objective study of these psychological phenomena. Methods: In a choice reaction task, subjects were asked to respond to tone pips by extending their fingers and to make non-semantic vocalizations as soon as they became aware of any errors. Results: In motor response-synchronized averages of instances in which subjects were aware of making errors, a biphasic cerebral potential occurred over the frontocentral scalp region 170 ms after the incorrect motor response and about 500 ms prior to any vocalization. It occurred 100 ms after the so-called error negativity (Ne), from which it was therefore distinguished. Conclusion: The recording of such activity may therefore provide an electrophysiological signature of perceptual awareness related to making errors. Significance: Recording this potential may facilitate the objective study of awareness to errors in other experimental contexts.

Perceived conflicts and errors in complex problem solving

In a behavioral experiment on 60 healthy volunteers, the Tower of London was employed as a complex visuo-spatial planning task. After each trial, participants were asked how difficult they found the task and whether they thought their solution was optimal. Results showed that objective problem difficulty affected behavioral performance as well as subjectively experienced difficulty and performance certainty. This pattern was influenced by experimental manipulation of participants' knowledge of objective problem difficulty: For optimally solved problems, performance certainty remained at high levels if such knowledge was provided, and strongly declined in more difficult problems if it was withheld. For nonoptimally solved problems, subjects' ratings indicated awareness of errors when they were informed about objective problem difficulty; otherwise, performance certainty declined from intermediate to low levels in more difficult problems. No such interaction was observed with regard to ratings of subjective problem difficulty. Additional structural equation modeling revealed that subjective awareness of errors and processing conflicts can be considered as independent only for optimally solved trials in which the optimal solution was known to the participants. We conclude that participants' ratings of problem difficulty and performance certainty can be regarded as indicators of at least partly distinct processes of performance monitoring, and that studies of complex problem solving incorporating such subjective measures may enhance the empirical basis of current theories of executive functioning.

Knowledge and beliefs associated with refractive errors and undercorrection: the Singapore Malay Eye Study

Background/aims:Refractive errors, especially if undercorrected, are a common and important cause of poor vision, particularly in Asia. The knowledge and beliefs of refractive errors and possible impact of undercorrection in...

Effects of Glasgow Outcome Scale Misclassification on Traumatic Brain Injury Clinical Trials

The Glasgow Outcome Scale (GOS) is the primary endpoint for efficacy analysis of clinical trials in traumatic brain injury (TBI). Accurate and consistent assessment of outcome after TBI is essential to the evaluation of treatment results, particularly in the context of multicenter studies and trials. The inconsistent measurement or interobserver variation on GOS outcome, or for that matter, on any outcome scales, may adversely affect the sensitivity to detect treatment effects in clinical trial. The objective of this study is to examine effects of nondifferential misclassification of the widely used five-category GOS outcome scale and in particular to assess the impact of this misclassification on detecting a treatment effect and statistical power. We followed two approaches. First, outcome differences were analyzed before and after correction for misclassification using a dataset of 860 patients with severe brain injury randomly sampled from two TBI trials with known differences in outcome. Second, the effects of misclassification on outcome distribution and statistical power were analyzed in simulation studies on a hypothetical 800-patient dataset. Three potential patterns of nondifferential misclassification (random, upward and downward) on the dichotomous GOS outcome were analyzed, and the power of finding treatments differences was investigated in detail. All three patterns of misclassification reduce the power of detecting the true treatment effect and therefore lead to a reduced estimation of the true efficacy. The magnitude of such influence not only depends on the size of the misclassification, but also on the magnitude of the treatment effect. In conclusion, nondifferential misclassification directly reduces the power of finding the true treatment effect. An awareness of this procedural error and methods to reduce misclassification should be incorporated in TBI clinical trials.

Recurrent Error Pathways in HFACS Data: Analysis of 95 Mishaps with Remotely Piloted Aircraft

According to Reason's model of accident causation, mishaps tend to fall into recurrent patterns. This model is the foundation for the Human Factors Analysis and Classification System (HFACS), which is now widely used in aviation accident analysis. The purpose of this study was to determine if it was possible to use HFACS to identify recurrent error pathways within an existing mishap database. All MQ-1 Predator remotely piloted aircraft (RPA) mishaps and safety incidents reported to the Air Force Safety Center during fiscal years 1997-2005 were evaluated and entered into a mishap database (N = 95). An exploratory principal component analysis (PCA) was used to assess the factorial structure within the set of crewmember-related mishaps (N = 48). The results of the PCA were used to define recurrent pathways from latent to active failure and hence mishaps. A tree diagram was subsequently created to quantitatively assess the associations identified in the PCA. Four factors were identified, each consisting of one of the HFACS categories of active failure and one or more categories of latent failure. Two additional factors were identified, consisting of fatigue and motivational latent failures. Based on analysis of the tree diagram, the majority of mishaps were caused by latent failures involving organizational factors and the technological environment. It was possible to identify four recurrent error pathways associated with the four types of HFACS active failures within this sample of RPA mishaps. Two of these error pathways, accounting for 57% of crewmember-related mishaps, were consistent with situation awareness errors associated with perception of the environment.

Potentially fatal vaporizer incident

Editor: We wish to report a potentially fatal critical incident that occurred during an elective operating theatre list. A similar problem [1] has been recently highlighted by the MHRA but without the emphasis of its potentially fatal nature (Fault in Draeger Vapor 2000/D-Vapor Vaporizer series with the interlocking device, MDA/2006/030) [2]. This series of vaporizers for isoflurane and sevoflurane has an interlocking safety system consisting of a hole with a nib in the coloured disk on the top of the vaporizer, at 180° to each other. This prevents the locking bar being inserted into the hole unless the vaporizer is turned off. It is known that damage to or loss of this plastic nib can result in two vaporizers being turned on simultaneously [3]. The presence of a unilateral nib at the 5% delivery mark masks the absence of the second nib at the 0% delivery mark due to the nature of the vaporizer position on the anaesthetic machine at the left-hand side (Fig. 1). This machine thus passed the routine AAGBI Recommendations for Checking Anaesthetic Equipment [4].Figure 1.: Damaged nib.On transfer of the patient to the operating room, initially isoflurane was switched on to 1-2%. The desflurane vaporizer was then mounted as the anaesthetist's agent of choice and switched on after switching off the isoflurane vaporizer - or so we thought. What happened next is shown in Figure 2. The vaporizer on the left is locked at 5% isoflurane. This was caused when the anaesthetist inadvertently turned the vaporizer dial anticlockwise to switch off instead of in a clockwise direction (i.e. the wrong way) and engaged the interlocking device, which then allowed operation of the desflurane vaporizer. We recognized this mistake a few seconds after it occurred preventing any harm to the patient. The interlocking device required considerable force to disengage from the isoflurane vaporizer.Figure 2.: Isoflurane vaporizer at 5% with interlocking device on and desflurane also switched on at 4%.Two issues need to be addressed: Awareness of this potential error as the number of general anaesthetics given daily with these agents is large, increasing the chances of a similar episode that might not be corrected so speedily. The manufacturer needs to urgently rectify this problem. This incident emphasizes the fact that despite repeated checking, errors can and do occur and it is necessary to be vigilant for new errors as our anaesthesia delivery systems become more complicated and modernized. We have informed Draeger and look forward to their comments.

Errors of intravenous fluid infusion rates in medical inpatients

Prescriptions for intravenous (i.v.) fluids in hospitals may not be closely adhered to. This study prospectively examined whether prescribed i.v. fluids are administered at the correct rate. During a four-week period, the i.v. infusion rates in patients requiring continuous i.v. fluids and cared for by a single medical team in a district hospital were studied. The periods over which i.v. crystalloid fluid bags were administered were compared with the time prescribed. Of a total 207 bags, 53 (26%) were correctly administered at the prescribed rate (percentage error 10% to -10%), 138 bags (67%) were infused too slowly and 16 bags (8%) were infused too fast. Overall, the median (interquartile range) absolute percentage error (positive or negative) for all infused bags was 23% (9.7-50). Thirty-nine per cent of bags were infused accurately when a metered pump was used, compared to 21% of bags infused accurately when a metered pump was not used (p < 0.01). Marked inaccuracies in i.v. fluid infusion rates are common, and do not seem to be perceived by staff as important. Metered pumps improve accuracy. Increased awareness of such errors, and the routine use of metered pumps should help improve the accuracy of i.v. fluid infusion rates.

Housestaff and Medical Student Attitudes Toward Medical Errors and Adverse Events

A lack of formal patient safety curricula has contributed to the suboptimal training of medical students and housestaff. Attitudes of physician trainees regarding medical errors and adverse events were surveyed in a pilot study. Five hundred sixty-three physician trainees were surveyed at an urban teaching hospital. Five domains were evaluated using a factor analysis as they relate to patient safety: knowledge, self-efficacy, awareness of safety culture, barriers/facilitators, and awareness of human factors. One hundred fifty-eight (28%) trainees completed the survey, with 22% (n = 35) describing exposure to at least one adverse medical event. The survey showed good internal validity and reliability. Respondents who reported exposure to adverse events demonstrated a lower awareness of human factor errors (p = .0017) and lower awareness of the hospital's approach to safety (p = .033). Older respondents scored higher on measures of self-efficacy than younger trainees (p = .042). The exposure of physician trainees to errors and adverse events can have a negative effect on their attitudes and competencies. Exposure to adverse events and the institution's response may decrease both error reporting and the willingness to adopt safety practices. The results support the need for implementing a sustained patient safety curriculum that promotes learning regarding adverse events.

Fallacious Reasoning and Complexity as Root Causes of Clinical Inertia

The quality gap and clinical inertia are stubborn problems that are prevalent, but difficult to explain. We puzzle why conscientious practitioners, who are keenly aware of appropriate evidence based treatments, avoid initiating or intensifying treatments. This has caused some to question that there may be hidden causes for these errors in the planning of chronic care. A timely clue enabled the author to recognize his flawed reasoning when planning the care of two elderly women sustaining hip fracture. The sudden awareness of planning error motivated a study of the under-treatment of chronic disease. Reference to fallacy and planning error were rare in the medical literature, but fallacious reasoning best explained the author's conscious decision to withhold evidence based treatment for osteoporosis from many elderly patients. Increasing awareness of cognitive error had immediate impact on the treatment of osteoporosis in nursing home residents. Similar planning errors for the care of other chronic illnesses were readily identified. These errors could be attributed not only to the author, but to other conscientious physicians involved in the patient's care as well as the patients' families. The author's observations permitted a homegrown taxonomy of fallacious reasoning and complexity as it was observed. Examples of the fallacies and complexities are presented within the context of the author's four year study. Fallacy and complexity contribute to clinical inertia and planning error on a regular basis in nursing homes. Gestalt for planning error, fallacy and complexity is not widely available to physicians, and they are remarkably unaware that their own cognitive limitations and biases have unintended adverse consequences for their patients. The author proposes that study of the cognitive psychology of longitudinal care is sorely lacking in current medical training. This type of reasoning differs from diagnostic reasoning, and may utilize a different part of the brain. Training in planning error should be introduced early, and refreshed periodically, as clinicians become more highly trained. Paradoxically, training and success seems to render the practitioner progressively more resistant to recognizing his entrenched fallacious belief systems.