Error Prevention Research Articles

Design and evaluation of a serious video game to treat preschool children with speech sound disorders

Speech sound disorder (SSD) is one of the most common communication disorders in children, which must be diagnosed and treated in childhood to prevent its negative psychological, occupational, and social consequences in adulthood. The use of serious games is one technology that could help treat SSD. This study aims to design and evaluate the usability of a digital game for 3–6-year-old children. This developmental study was carried out in three main stages: determining information requirements, designing and developing a digital game, and evaluating the usability of the designed game. In the first stage, the consonants, syllables, words, and sentences that should be used in the game were determined through focus group sessions and a questionnaire completed by 30 speech-language pathologists (SLPs) in two Delphi rounds. In the designing and developing stage, the game design document was first written, and then sketches and wireframes were drawn based on this document. Then, the game was developed in the second phase using Java programming language. In the third stage, the usability of the designed game was evaluated by six experts and 22 SLPs using Nielsen's usability heuristics and the Post-Study System Usability Questionnaire (PSSUQ), respectively. Also, the usability of the game was evaluated by ten children. To determine the information requirements, SLPs confirmed 23 consonants, 138 syllables, 564 words, and 69 sentences to teach children the game. According to Nielsen's usability heuristics, the designed game had 23 unique usability problems with a mean severity of 2.29. "User control and freedom," with five usability problems, was the most frequently identified problem, and "error prevention," with a mean severity of 3.83, was the most severe problem. The results of the SLPs’ evaluation also showed that the "interface quality" of the designed game obtained the highest score, with a mean score of 6.25 out of 7. Also, 100% of children stated that the game was designed beautifully, and 90% of children also liked the game. A serious game designed for children with SSDs achieved satisfactory results in usability evaluation. Therefore, this smartphone-based game can be easily used among these children to provide fun therapy sessions under the supervision of parents.

Toward Enhanced Healthcare Efficiency: The Impact of Digitizing Medical Records

The digitization of health care records represents a transformative shift in managing patient and service information, offering substantial benefits to efficiency, safety, and quality of care globally. Centralizing and standardizing patient data through electronic record systems facilitates organized storage and swift access to clinical information, reducing reliance on paper records and enhancing decision-making across clinical and administrative domains. Improved coordination among healthcare professionals ensures seamless care delivery, crucial for complex conditions and error prevention. Automated administrative processes streamline operations, reducing errors and costs while bolstering efficiency. Data security is paramount, with electronic systems employing advanced encryption and authentication to safeguard patient information and ensure compliance with privacy regulations. Moreover, digitalization supports robust data analysis, enabling health institutions to identify trends and inform evidence-based practices, contributing to ongoing medical advancements and public health strategies.

A Comprehensive Analysis of Medication Errors on Antimicrobials in a Tertiary Care Hospital of Northern India

Background: Medication errors, resulting from incomplete understanding, pose significant risks to patient safety. Antimicrobial medication error is a global concern further exacerbated by underreporting. This study aims to determine the prevalence of antimicrobial medication errors at a tertiary care medical facility. Methodology: A retrospective study was conducted over six months. Antimicrobial medication errors were analyzed and categorized as prescription, transcription, indenting, dispensing, and administration errors. A total of 208 antimicrobial medication errors were analyzed using the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) risk index. Results: Among 6,439 medication charts assessed, 558 (9%) medication errors were identified, with antimicrobial errors accounting for 208 (37.2%). Prescription errors were the most prevalent (61%), followed by transcription errors (16%) and administration errors (11%). Dispensing, indenting, and documentation errors occurred at rates of 8%, 2%, and 2%, respectively. The primary causes of errors were incorrect doses (47.2%) and frequencies (30%). Approximately 55.3% of antimicrobial medication errors were classified as Category C according to the NCCMERP risk assessment. Conclusion: Prescription errors represent the majority of antimicrobial medication errors, underscoring the need for enhanced vigilance among consultant physicians during prescription writing and drug schedule checks.

Development and Integration of a Digital Twin Model for a Real Hydroelectric Power Plant.

In this study, a digital twin model of a hydroelectric power plant has been created. Models of the entire power plant have been created and malfunction situations of a sensor located after the inlet valve of the plant have been analyzed using a programmable logic controller (PLC). As a feature of the digital twin (DT), the error prediction and prevention function has been studied specifically for the pressure sensor. The accuracy and reliability of the data obtained from the sensor are compared with the data obtained from the DT model. The comparison results are evaluated and erroneous data are identified. In this way, it is determined whether the malfunction occurring in the system is a real malfunction or a malfunction caused by measurement or connection errors. In the case of sensor failure or measurement-related malfunction, this situation is determined through the digital twin-based control mechanism. In the case of actual failure, the system is stopped, but in the case of measurement or connection errors, since the data are calculated by the DT model, the value in the specified region is known and thus there is no need to stop the system. This prevents production loss in the hydroelectric power plant by ensuring the continuity of the system in case of errors.

Bi-lingual content validation of the Non-Technical Skills for Operating Room Nurses (NOTSORN) tool: A Delphi study

BackgroundThe primary responsibility of the operating room nurse is to prevent adverse events and patient harm during surgery. Since most preventable adverse events are the result of breakdowns in communication and teamwork, or non-technical skills, training such skills should strengthen the operating room nurses’ error prevention abilities. Behavioural marker systems operationalise non-technical skills; however, previous systems for operating room nurses do not cover the full extent of non-technical skills used by operating room nurses. Thus, the Non-technical Skills for Operating Room Nurses (NOTSORN) behavioural marker system was developed. ObjectiveThe objective of this study was to establish face and content validity of the Non-Technical Skills for Operating Room Nurses behavioural marker system. This multi-item scale measures individual non-technical skills in operating room nursing. ParticipantsA purposive sample of operating room nursing researchers, educators, and senior clinicians from nine countries worldwide. MethodsA two round, Delphi panel with international experts in operating room nursing. The survey was administered online. Content validity index (CVI) was used to measure agreement among panel members. Results25 operating room nurse experts participated in the online Delphi study. After round 1, 56 items were accepted, 26 items were revised, and 1 item was dropped. Following round 2, all items (6 with minor revisions) were accepted. Thus, the Non-technical Skills for Operating Room Nurses tool comprise 81 items. The scale level CVI score for the final 81 item tool was 0.99. The individual item level CVI scores ranged from 0.9 to 1.0. ConclusionsThe Non-Technical Skills of Operating Room Nurses behavioural marker system is a nuanced tool with a myriad of non-technical skills operating room nurses need to undertake their work safely. The tool's intended use includes student/trainee supervision, supervision of novice operating room nurses, self-reflection for performance reports, and in operating room nursing education. Over time, use of the tool has the potential to contribute to patient safety in the operating room. Tweetable abstractThe NOTSORN tool provides a comprehensive and holistic evaluation of OR nurses' non-technical skills for safe surgical performance

Using Vocal-Based Emotions as a Human Error Prevention System with Convolutional Neural Networks

Human error is a mark assigned to an event that has negative effects or does not produce a desired result, with emotions playing an important role in how humans think and behave. If we detect feelings early, it may decrease human error. The human voice is one of the most powerful tools that can be used for emotion recognition. This study aims to reduce human error by building a system that detects positive or negative emotions of a user like (happy, sad, fear, and anger) through the analysis of the proposed vocal emotion component using Convolutional Neural Networks. By applying the proposed method to an emotional voice database (RAVDESS) using Librosa for voice processing and PyTorch, with the emotion classification of (happy/angry), the results show a better accuracy (98%) in comparison to the literature with regard to making a decision to deny or allow a user to access sensitive operations or send a warning to the system administrator prior to accessing system resources.

Impact of pharmacist‐led discharge medication reconciliation on error and patient harm prevention at a large academic medical center

AbstractIntroductionMedication errors during hospital discharge can lead to adverse outcomes, medication‐related readmissions, and increased health care costs. Pharmacist‐led medication reconciliation at discharge is a potential solution to mitigate poor outcomes and optimize medication safety.ObjectivesThis study aimed to quantify medication errors identified at discharge and characterize the severity of patient harm prevented following pharmacist‐led discharge medication reconciliation. Cost avoidance analysis was conducted to determine its associated financial impact.MethodsPatients, who were discharged from an adult internal medicine service during October 2022, were included in this one‐month pilot prospective quality improvement study. The number of errors at discharge were documented, categorized by type, and adjudicated for severity of potential harm. Error severity was classified based on a modified National Coordinating Council for Medication Error Reporting and Prevention Medication Error Index. Cost avoidance was calculated based on whether each error would have resulted in additional medical encounters and length of stay.ResultsThirty‐one patients were included in the analysis. Forty errors were identified by pharmacist‐led medication reconciliation at discharge, with a mean of 1.3 ± 1.9 errors per patient and 68% of patients having at least one error. The most common errors were duplication of therapy (25%) and medication access barriers at discharge (25%). The severity of errors included low (22.5%), serious (75%), and life‐threatening harm (2.5%). Thirty‐five percent of errors could have led to emergency visits or hospital readmissions. The estimated total cost for errors was $25 600. Pharmacist labor cost for reconciliation was $816. Cost avoidance was $24 784 from the 14 errors at discharge that could have resulted in additional emergency or inpatient visits.ConclusionPharmacist‐led medication reconciliation at discharge may prevent harm from reaching patients, decrease cost from unnecessary health encounters, and stop the error from continuing across transitions of care.

The prevention of medication errors in the home care setting: a scoping review.

The changes in health, social and demographic needs impose new approaches to cures and care without giving up patients' safety. Although several studies analysed the patient safety approach and strategies, the literature considering the home care setting seems still scarce. The analysis of the phenomenon of medication errors in the primary care setting highlights the necessity of exploring the specific variables to understand how to prevent or reduce the occurrence of a medication error in the home context. This review investigates the main preventive strategies implemented at the patients' home to prevent and/or limit the possibility of a medication error. The scoping review was conducted under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ex-tension for Scoping Reviews (PRISMA-ScR) statement and based on the guidelines of the Joanna Briggs Institute. No time or language limit was set to obtain the most comprehensive results possible. The following databases were queried: PubMed, Cochrane, CINAHL, ERIC and PsycINFO via EBSCO. All literature published up to 31 December 2022 was considered for data collection. The main preventive strategies implemented in the patient's home to prevent a medication error are: Multidisciplinary teams, therapeutic reconciliation and computerised systems that improve information sharing. As evidenced by all of the included studies, no educational intervention or preventive strategy individually reduces the risk of making a medication error. It would be desirable for healthcare professionals to be constantly updated about their knowledge and understand the importance of introducing the aforementioned preventive strategies to guarantee safe care that protects the person from me-dication errors even at the patient's home.

Usability Testing of the AIS Mobile Application Using the User Centered Design Method for New Information Systems Students at UIN Syarif Hidayatullah Jakarta

Many individuals all across the world now depend heavily on their smartphones in their daily lives. Building mobile applications gives the chance to connect with a very sizable and growing user base. Mobile applications have a large market potential due to their constantly growing user base. Icons on the phone screen make it simple and quick to access mobile applications. Users don't need to open a browser or type a website address in order to utilize an application; they simply need to click on the application icon. According to the results of the questionnaire given to 21 respondents, UIN Jakarta's AIS Mobile application scored 64.87% on usability. Due to this, the User Centered Design build method was used in this study to build the AIS website for UIN Syarif Hidayatullah Jakarta in order to increase the usability value of the website in the aspects of Learnability, Efficiency, Memorability, Error Prevention, and Satisfication Assessment.

Improving Team Members' Attention During the OR Briefing or Time Out.

Effective coordination among health care professionals is crucial to achieving optimal outcomes. In the OR, even minor errors can have catastrophic consequences. To mitigate the risk of error, health care professionals have adopted a briefing culture like that used in the aviation industry. Briefings are essential to ensure that everyone involved in a procedure knows the plan and potential risks and is prepared to perform their duties safely and effectively. The fundamental human sense involved in briefings is auditory perception; although important, hearing alone does not equate to focused attention. To enhance the efficacy of briefings, engaging the use of a second sense by adding a visual checklist may increase attentiveness and the chances of early error detection and prevention. Using a projection device may enhance all team members' engagement and participation during the briefing or time-out process and can be an effective tool for improving communication and reducing errors.

False Positives and Deceptive Errors in SQL Assessment: A Large-Scale Analysis of Online Judge Systems

Online Judge Systems (OJSs) play a crucial role in evaluating SQL programming skills. However, OJSs may not accurately evaluate students’ queries as the error-detection capabilities of test sets are insufficient, resulting in false positives that can mislead students and hinder their learning. This study analyzes a large-scale OJS’s evaluation dataset and identifies more than 110,000 (1.94%) false-positive queries. It also validates existing SQL error categorization and reveals a new type of logical error called deceptive error, which occurs when students construct queries that pass specific test cases but fail to solve the actual problem. This type of error has been overlooked in previous research and can provide new insights into how to improve OJSs by enhancing test cases and feedback. This study contributes to the understanding of assessment and evaluation practices and processes in programming education, particularly the contribution that OJSs make to student learning and to course, staff, and institutional development. It also suggests error prevention and detection techniques that can improve the effectiveness and fairness of OJSs in programming education and competitions.

Detection of Adverse Events With the Austrian Inpatient Quality Indicators.

Indicators based on routine data are considered a readily available and cost-effective method for assessing health care quality and safety. The Austrian Inpatient Quality Indicators (A-IQI) have been introduced in all Austrian public hospitals as a mandatory quality measurement. The purpose of this study was to assess the value of conspicuous A-IQI in predicting the presence of adverse events (AEs). We conducted an exploratory study comparing all indicator-positive patient cases contributing to 18 conspicuous A-IQI indicators to randomly selected indicator-negative control cases regarding the prevalence and severity of AEs. Structured medical record review using the Institute for Healthcare Improvement Global Trigger Tool was used as the gold standard. In 421 chart reviews, we identified 158 AEs. 70.9% (n = 112) of the AEs were found in cases with a positive indicator. The relative risk of an AE occurring was 3.47 (95% confidence interval: 2.30, 5.24) in indicator-positive cases compared to indicator-negatives. The proportion of severe events (National Coordination Council for Medication Error Reporting and Prevention Index categories H and I) was 54.5% (n = 61) in indicator-positive cases and only 15.3% (n = 7) in indicator-negative cases. Overall sensitivity of the A-IQI was 68.2%, specificity 69.4%, positive predictive value 36.0%, and negative predictive value 89.6%. Our study shows that significantly more AEs and more severe AEs were found in cases with positive A-IQI than in indicator-negative control cases. However, studies with larger numbers of cases and with larger numbers of conspicuous indicators are needed for the validation of the entire A-IQI indicator set.

Prevalence of Medications Errors and Factors of Harmful Errors in Neonates and Paediatrics at Tertiary and Paediatric Hospitals: A Multicenter Study

Medication errors (ME) are human mistakes that may occur during drug use, prescribing administration or monitoring. This study aimed to determine the Prevalence of MEs among pediatric patients receiving tertiary treatment in pediatric speciality hospitals and describe their patterns and causes. Three institutions participated in a multicenter retrospective analysis. Reports of all MEs involving paediatrics aged ≤13 years who were hospitalised or visited the Emergency Department or outpatient clinics were reviewed 1 January 2019 - 31 December 2019. The National Coordinating Council for Medication Error Reporting and Prevention classification was used to categorise MEs and to define PRME (category CI) and patient–harming MEs (category EI). A retrospective study was conducted with a total of 318 MEs reported, with an overall prevalence of 0.9 per 1,000 patients. The Prevalence was markedly lower in the CHT (0.35 / 1,000 patients) than in KAMC and KFSH&RC (1.73 and 3.5). The highest rate of MEs was observed in admitted wards (14.69 / 1,000 patients). Most commonly, MEs occurred at the prescribing stage (81.1%), were caused by a physician (83.3%), and were discovered by the pharmacist (85.5%). Improper medication dosage (34.0%), frequency (14.2%), and duration (10.4%) were the three most common forms of MEs. Paediatric inpatient treatment has a significant frequency of MEs, accounting for 24% of hospitalisations. The ME may not get to the patient if independent double-check prescriptions, accurate medication reconciliation of new prescriptions against the previously prescribed, and improved medicine labelling and packaging techniques are used.

Error prevention adaptive optimization model for power dispatch under time redundancy control

Error prevention adaptive optimization model for power dispatch under time redundancy control

Impact of Implementing TQA Principles on Organizational Development: A Field Study in Private Universities in Amanat Al Asema (Sana’a)

This study aimed to identify the impact of implementing TQA principles on organizational development in private universities in Amanat Al Asema, Sana’a. To achieve this, the study adopted the descriptive analytical method, and its population consisted of leadership positions in (9) universities who were (427) leaders, (210) of which were selected using the stratified proportional random method. The SPSS was used for processing and analyzing the data. The study results revealed a positive impact of TQA principles on organizational development, with a difference in such an impact due to different dimensions. The dimension of fact-based decision-making showed more impact on the organizational development, whereas the dimension of focusing on the learning and teaching process had less impact. The principles of TQA (support and commitment of the higher management to applying principles of TQA; focus on the customer; prevention of errors before occurrence) did not show any impact on the organizational development in the universities under study. The study recommends strengthening the practice of TQA principles due to their positive impact on organizational development, paying more attention to developing the learning and teaching process, and improving the level of organizational development in the universities.

The Impact of Big Data Analytics on The Detection of Errors And Fraud in Accounting Processes

Purpose: This study aims to discuss and investigate the role of big data analytics (BDA) in promoting error detection and preventing fraud in accounting operations. Methodology: It uses a secondary method of data collection (desk study) to explore the potential impact of BDA in enhancing error and fraud prevention on six key considerations including data quality and integrity; data privacy and security; real-time monitoring and alerts; integration with internal controls; ethical implications; and human experience. Finding: The analysis shows that the BDA enhances fraud detection by integrating data from multiple sources, using sophisticated algorithms to identify anomalies. Reduces false positives and improves accuracy. However, human expertise is essential for ethical standards and transparency. Implications: It has significant implications for the accounting profession, as it provides an addition in both theoretical knowledge and practical applications, theoretical implications include developing accounting knowledge, developing data-driven models, establishing ethical frameworks, and promoting interdisciplinary insights. On a practical level, it provides guidance for improving financial accuracy, fraud prevention, regulatory compliance, data-driven decision-making, and professional development for accountants. Contribution: It contributes to bridging the research gap in the aspect related to the analysis of big data and its impact on the quality of accountants' work, as this topic is of high importance to researchers, governments, policymakers, industries, companies, investors, and regulators, bridging the gap between accounting and data analytics. This interdisciplinary approach is critical in understanding the evolving landscape of the impact of big data analytics on financial transparency and accuracy of financial reporting. Article Type: Research Paper.

Medication Reconciliation

The Institute of Medicine (IOM) stated that preventable medication errors are the mostcommon type of errors in healthcare. It is of fundamental significance when building a safercare continuum, as it highlights the reason for continuous and more vigilant medicationreconciliation and required effort at all interfaces of care, including community. Without arobust medication reconciliation process, the potential for catastrophic outcomes remains aconstant concern. Prevention of medication errors is essential through strategies that are basedin evidence of medication reconciliation strategies on medication errors in community

Aircraft maintainability verification evaluation based on fuzzy analytic hierarchy process

This paper uses the fuzzy analytic hierarchy process to establish the mathematical model of aircraft maintainability verification in the flight test stage. The maintainability evaluation index system is constructed from the factors that affect the aircraft maintainability level, such as equipment layout and accessibility, cover design, marking and error prevention, standardization and interchangeability, and human factor engineering. Through case analysis, the application of this method in the maintainability verification of the military aircraft flight test phase is introduced.

Exploring medical and nursing students’ perceptions about a patient safety course: a qualitative study

BackgroundEducating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students.MethodsA dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021–2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo.ResultsThe findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety.ConclusionsStudent perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.

Analysis of local government supervision in surface mining: The case of Bulukumba Regency

Supervision is the prevention or correction of errors, irregularities, discrepancies, and misappropriations that are not in accordance with the objectives of the predetermined authority. This study aims to determine how the form of local government supervision in supervising rock quarry mines in Bontotiro District, Bukukumba Regency. This study used a qualitative descriptive approach, and the data collection used observation, interviews, and documentation. Data was analyzed through the stages of data collection, data reduction, data presentation, and conclusions. This study shows how local government supervision of rock quarry mines in the study area is seen from two forms of supervision. First, preventive supervision was carried out before the implementation of mining activities through the supervision of exploration Mining Business Permits (IUP) for exploration implementation and Mining Business Permits (IUP) for production operations. Second, repressive supervision carried out during the implementation of mining activities refers to the supervision of Rock Excavation Production Operation Activities.