Procedural Errors Research Articles

A Novel Modularization Design Method of PM Biased SCFCL Considering Leakage Flux Effect and Permeance Matrix Modeling

A DC system saturated core fault current limiter (DCSFCL) was proposed to limit the fast rising trend of fault current in HVDC system. However, traditional method to calculate and design the DCSFCL tend to neglect leakage flux around the permanent magnet (PM), leading to large calculation error and inappropriate design procedure. The novel contribution of this paper is that it proposed a modularization method to analyze the permeance of both PM and adjacent air. Hence, the leakage flux effect is considered properly and a more accurate permeance matrix can be derived in a pure mathematical way. In this case, DCSFCL can be calculated much faster than the FEA simulation program with a promising accuracy regarding fault limiting performance. More importantly, design flow of the DCSFCL and related PM biased devices was given as well. Calculation result shows that inductance value calculated by the proposed method has less than 1% error compared with fine meshed FEA simulation result and about 20% increase in accuracy compared with traditional method that neglects PM leakage flux effect. Prototype of the DCSFCL was also built and experimental tests were carried out to verify the correctness of the proposed method.

The relationship between consumer engagements with Super Bowl ad tweets and the advertisers’ official Twitter accounts: a panel data analysis of 2019 Super Bowl advertisers

This study aims to examine the influence of consumer engagement with Super Bowl ad tweets, on their engagement with the advertiser’s official Twitter account. Using Python, audience engagement data were collected from the Super Bowl advertisers’ official Twitter accounts on a daily basis from two days before the game until 10 days after the game; this procedure resulted in 351 cases for 27 advertisers in a balanced panel dataset. Overall, the results of panel regression analyses employing a feasible generalized least squares (FGLS) procedure and panel-corrected standard error (PCSE) estimates support the hypothesis predicting transference of engagement from Super Bowl ads tweets to the advertisers’ official Twitter accounts. In particular, of the three engagement metrics, the number of retweets of and favorites on the Super Bowl ad tweets significantly increased the numbers of followers and favorites on the official Twitter accounts of the Super Bowl advertisers. The theoretical and managerial implications of the findings are discussed.

Methodology for conducting and analyzing land surveying examinations

Geoscience does not investigate the methods of producing land surveyors in the framework of court cases and reviews produced after the analysis of this expertise type. The article proposes the author’s methods of this field of study: test, technological methods and method of typical errors, which are developed and justified. The paper analyzes the errors of 176 land surveyors and provides statistics of such errors. They are classified into design errors, procedural errors, and errors of a special technical nature. The article analyzes the meaning of each error type (and introduces the concept of gross and minor errors). It proposes the author’s method of producing reviews of land surveyors which is a technological method. It is reviewed in detail; it is indicated that it is in the testing stage and has received a positive response. The study suggests the formation of reliable complete scientific research in the framework of the expertise in land disputes, which leads to more fair and well-grounded court decisions.

Analysis of multi-cavity molding of parts with different geometries

In the industrial processes of injection molding, one of the basic requirements is a uniform temperature filed within workpiece and the mold cavities. In the case of simple geometry of workpiece and mold with single cavity achieving a uniform temperature field is not a critical issue. However, if one deals with parts of complex geometries, multi-cavity molds and asymmetric layout of different forms in the mold additional analyses of the runner and cooling system are necessary in order to obtain the required quality and accuracy of end the products. Disposition and dimensions of both runners and cooling channels are directly related to the geometry of finished parts and material properties. In that sense, virtual models and numerical simulations of injection molding processes based on the finite element method are very effective tool which enable accurate prediction of potential problems and significant reduction of trial and error procedure. In this paper, FEM software package Moldex3D was employed for simulation and analyses of injection molding process in which pipe fittings Ø75/45o and Ø75/90o are produced using a mold with two asymmetric cavities.

Using Failure Mode and Effects Analysis in Blood Administration Process in Surgical Care Units: New Categories of Errors.

Blood administration failures and errors have been a crucial issue in health care settings. Failure mode and effects analysis is an effective tool for the analysis of failures and errors in such lifesaving procedures. These failures or errors would lead to adverse outcomes for patients during blood administration. The study aimed to: use health care failure mode and effect analysis (HFMEA) for assessing potential failure modes associated with blood administration processes among nurses; develop a categorization of blood administration errors; and identify underlying reasons, proactive measures for identified failure modes, and corrective actions for identified high-risk failures. A cross-sectional descriptive study was conducted in surgical care units by using observation, HFMEA, and brainstorming techniques. Prioritization of detected potential failures was performed by Pareto analysis. Eleven practical steps and 38 potential failure modes associated with 11 categories of errors were detected in this process. These categories of errors were newly developed in this study. In total, 17 of 38 potential failures were detected as high-risk failures that occurred during the sample-drawing, checking, preparing, administering, and monitoring steps. For cause analysis of failures and errors, proactive suggested actions were undertaken for 38 potential failure modes, and corrective actions for 17 high-risk failures. HFMEA is an efficient and well-organized tool for identification of and reduction in high-risk failures and errors in the blood administration process among nurses without building punitive culture. This tool also helps pay attention to redesigning and standardizing the blood administration process as well as providing training and educational programs for providing knowledge.

Impact of Simulation-Based Training on Radiation Therapists’ Workload, Situation Awareness, and Performance

PurposeThis study aimed to assess the impact of simulation-based training intervention on radiation therapy therapist (RTT) mental workload, situation awareness, and performance during routine quality assurance (QA) and treatment delivery tasks. Methods and MaterialsAs part of a prospective institutional review board–approved study, 32 RTTs completed routine QA and treatment delivery tasks on clinical scenarios in a simulation laboratory. Participants, randomized to receive (n = 16) versus not receive (n = 16) simulation-based training had pre- and postintervention assessments of mental workload, situation awareness, and performance. We used linear regression models to compare the postassessment scores between the study groups while controlling for baseline scores. Mental workload was quantified subjectively using the NASA Task Load Index. Situation awareness was quantified subjectively using the situation awareness rating technique and objectively using the situation awareness global assessment technique. Performance was quantified based on procedural compliance (adherence to preset/standard QA timeout tasks) and error detection (detection and correction of embedded treatment planning errors). ResultsSimulation-based training intervention was associated with significant improvements in overall performance (P < .01), but had no significant impact on mental workload or subjective/objective quantifications of situation awareness. ConclusionsSimulation-based training might be an effective tool to improve RTT performance of QA-related tasks.

STUDY OF PHYSICAL PROCESSES IN THE DIRECT CURRENT LINK OF THE LOADING-BACK SCHEME OF ASYNCHRONOUS MACHINES

The article notes the tendency of introducing asynchronous engines, entailing the necessity to introduce the equipment which is intended to carry out maintenance, repair and acceptance check-outs. The general part of test circuits for asynchronous motors by the loading-back method with two controlled inverters is emphasized. The mathematical model of similar schemes’ functioning is shown. The article gives the results obtained by mathematic simulation of physical processes in the direct current link in the loading-back scheme for asynchronous machines Significant ripple voltage of constant voltage and DC in these circuits is noted. The issue of measuring power in the DC link passing through one inverter to the test engine and through another inverter from the load generator is considered. The authors carried out calculation of the capacities mentioned in the steady state modes for asynchronous machines with nominal power of 0.37 kW, 5.5 kW and 250 kW at different values of capacitor capacitance included in the DC link. Basing on the results of calculations, the authors found the dependence between the relative value of the procedural error in determining power in the DC link by the product of the current values of pulsed voltages and current. The current value from the product of instantaneous values of voltage and current at some time interval was taken as the true value of power. It is shown that at the capacitor capacity above some critical value this procedural error does not exceed 0.9% at the nominal power of the test engines 0.37 kW; 0.3% – at the power of 5.5 kW; 0.2% – at the power of 250 kW. This error increases dramatically when capacitor capacitance decreases. It is shown that the value of the capacitance corresponding to the inflection of the considered dependence approximately corresponds to the value necessary for limiting ripple voltage in the DC link of up to 600 V.

A Novel MEMS Gyroscope In-Self Calibration Approach.

This paper presents a novel approach for hand-held low-cost MEMS (micro-electro-mechanical system) gyroscope in-self calibration. This method does not need the support of external high-precision equipment compared with traditional calibration scheme and can be accomplished by user hand rotation. In this approach, Kalman filter is designed to perform the calibration procedure and estimate gyroscope bias error, scale factor error and non-orthogonal error. The system observability is analyzed and the dynamic rotating conditions under which the sensor errors become observable are derived. The design principles of optimal calibration procedure are provided as well. Both simulated and practical experiments are carried out to test the validation of the proposed calibration algorithm. The achieved results demonstrate that the introduced approach can provide promising calibration scheme for the low-cost MEMS gyroscope.

Effects of graphene oxide on PCR amplification for microbial community survey

BackgroundGraphene oxide (GO) has been suggested as an efficient assistant additive to eliminate non-specific amplification of the polymerase chain reaction (PCR). Although many studies have focused on exploring its molecular mechanism, the practice of GO on the quantitation of microbial community has not been implemented yet. In this study, GO was added in PCR system to explore the changes on removing typical amplification errors, such as chimera and mismatches on two kinds of mock communities (an evenly mixed and a staggered mock communities) and environmental samples.ResultsHigh-throughput sequencing of bacterial and fungal communities, based on 16S rRNA genes and internal transcribed spacers (ITS) respectively, showed that GO could significantly increase large segmental error (chimeric sequence) in PCR procedure while had no specific effect on point error (mismatched sequence). Besides, GO reduced the α-diversity of community, and changed the composition of fungal community more obviously than bacterial community.ConclusionsOur study provides the first quantitative data on microbial community level to prove the negative effect of GO, and also indicates that there may be a more complex interaction between GO and comprehensive DNA fragments in PCR process.

Judgment in Case C-265/17 P, Commission v UPS: the Form Matters—Due Process as a Necessary Condition to Efficient Decision-Making*

The CoJ upholds the annulment of the Commission's decision prohibiting UPS' acquisition of TNT for failure to disclose economic evidence and thereby confirms that due process is not an obstacle to efficient decision-making, but a necessary condition for it. On 16 January 2019, the Court of Justice of the European Union (‘CoJ’) confirmed the General Court’s annulment of the European Commission’s decision to prohibit UPS’ acquisition of TNT. The CoJ agreed that the Commission violated UPS’ rights of defence by basing its prohibition on an econometric model that it failed to disclose to the merging parties. The CoJ confirmed the General Court’s judgment at first instance, as well as Advocate General Kokott’s Opinion, stating that failure to disclose material changes to the econometric model constitutes a fundamental procedural error that vitiates the merger decision—regardless of whether the outcome might have been different absent the error.

Description of healthcare professionals’ attitudes on patient safety in the Tunisian operating rooms

Abstract Background Currently, ensuring surgical safety remain a worldwide challenge. The description of operating room professionals' attitudes toward patient safety in their work units helps to identify strengths and weaknesses in term of patient safety, allowing a clearer vision of the safety aspects that require special attention. This study aimed to describe healthcare professionals' attitudes on patient safety in the Tunisian operating rooms. Methods This is a cross-sectional descriptive study spread over a 6-month period (October-April 2018). It was conducted among healthcare professionals working in the operating rooms of the two teaching hospitals of Sousse (Tunisia). The measuring instrument used is the Operating Room Management Attitudes Questionnaire (ORMAQ), which consists of 60 items spread over 8 dimensions. The latter has been subjected to a transcultural validation process inspired from the Vallerand method. Data entry and analysis was done by the Statistical Package for Social Sciences (SPSS.20) software. Results A total of 303 professionals participated in the study (participation rate= 76.13%). The most developed dimension was teamwork and the least developed was “Procedural errors/ compliance”. Items' results show that 94.8% of professionals confirmed that seniors should encourage medical and paramedical staff to ask questions, 53.5% of professionals stated that personal problems can adversely affect their performance and 87.5% agreed that operating rooms' team members share responsibilities for prioritizing activities in high workload situations. In addition, 50.9% of participants reported that the managers don't listen to staff or care about their concerns. Conclusions Operating rooms professionals' attitudes toward patient safety in their work units reflect an alarming situation regarding the quality of healthcare provided to patients. These results should be taken into consideration to guide future intervention on quality management improvement. Key messages Considering human factors is essential to improve safety in operating rooms and has an important role in reducing the occurrence of adverse events in these settings. It is important to study the underlying attitudes that determine the human factors for a better understanding and resolution of patient safety problems.

1695P Risk assessment of admission procedures for cancer patients during the convalescence of COVID-19

Through great efforts, the outbreak of 2019 novel corona virus disease (COVID-19) has been slowing down in Wuhan. This study was to assess the potential errors of established admission procedures from a tertiary cancer center. A multidisciplinary team of eight frontline nurses and oncologists would conduct a failure mode and effects analysis (FMEA) to our established procedures. The FMEA consisted of 4 main steps, Including a detailed review of the on-going admission processes and the drawing of the corresponding flow chart, followed by repeated discussions of the possible errors among those processes, and then evaluation of the occurrence (O), detectability (D), and severity of impact (S) of each failure mode according to a scoring criteria (a five-point scale). Finally, the risk of errors were determined through a calculation of risk priority number (RPN=O*D*S). From March 24, 2020 to May 14, 2020, based on the established procedures, our center has screened 1,214 cancer patients in the oncology outpatient department and subsequent buffer wards. No nosocomial infection (among doctors or patients, or between patients and doctors) occurred. On the scale of RPN from high to low, ten high-risk steps were identified by FMEA, involving a failure of scheduled screening for particularly vulnerable populations, the failure of hand hygiene in outpatient and buffer wards, and the incorrect disposal of clinical waste by cleaning service staff. In addition, the psychological burden to cancer patients might increase the risk of buffer ward management failure. Self-review and continuous improvement for established procedures can minimized underlying mistakes. Increasing the approaches to treatment appointments, reasonably optimizing the working during for outpatient physicians, strengthening the awareness of hand hygiene (both physicians and patients), and setting up oncological psychological counseling groups will likely improve the potential error steps.

Piloting the FIRE: A Novel Error Management Training Simulation Curriculum for Fasciotomy Instruction

Multiple studies have demonstrated poor performance of lower extremity fasciotomy (LEF), highlighted by missed and/or inadequately released compartments. Incorporating error management training (EMT) into surgical simulation has been promoted as a way to gain deeper understanding of procedural errors and overall performance. The purpose of this study was to evaluate LEF performance using a Fasciotomy Improvement through Recognition of Errors (FIRE) simulation training curriculum to train novice surgical trainees. A mastery learning-based EMT curriculum was developed, and surgical residents were enrolled and pretested with a multiple-choice question (MCQ) written test, and a simulated fasciotomy using a lower leg model. Each trainee then watched a 15-minute narrated presentation followed by 2 rounds of fasciotomy error recognition and management training exercises to a mastery standard. During each round, trainees performed hands-on assessment of unique premade fasciotomy leg models containing a variable number of procedural errors. They were required to identify and propose corrective action for all errors. Serial rounds of remediation were implemented until the mastery standard was attained on both error identification rounds. All trainees were post-tested with the same MCQ and another simulated fasciotomy. All 14 residents had minimal experience with only 0.3 ± 0.6 fasciotomies performed prior to instruction. There were 3 ± 1.6 missed or inadequately released compartments on the pretest. Residents examined 14 ± 2.5 legs, including 2 ± 2.5 legs during remediation to attain mastery. All residents demonstrated significant improvement following the FIRE of Error curriculum for the MCQ (57% ± 16% vs 78% ± 13%; p = 0.01; Cohen's d = 1.4), fasciotomy score (10 ± 7.1 vs 28 ± 1.9; p < 0.001; Cohen's d = 3.6), and achieving a complete fasciotomy (14% ± 36% vs 93% ± 27%; p < 0.001; Cohen's d = 2.5). Only a single cumulative compartment was missed on post-testing. Implementation of a mastery learning-based EMT curriculum for fasciotomy simulation training results in significant improvement in fasciotomy technique without reliance on repeated procedure performance nor clinical fasciotomy exposure. This curriculum is a highly effective option for surgical trainees lacking fasciotomy training during residency.

System-Level Patient Safety Practices That Aim to Reduce Medication Errors Associated With Infusion Pumps: An Evidence Review.

ObjectivesIn this literature review, we discuss 2 system-level, nurse-targeted patient safety practices (PSPs) that aim to reduce medication errors associated with infusion pumps, including smart pumps. One practice focuses on implementing structured process changes and redesigning workflows to improve efficiencies with pump use. The other focuses on investing in initial and ongoing staff training on the correct use, maintenance, and monitoring of infusion pumps.MethodsTwo databases were searched for “infusion pumps” and related synonyms, along with relevant terms for each PSP. Articles were excluded if outcomes were not directly relevant to the PSP addressed in this review, the article was out of scope, or study design was insufficiently described.ResultsLimited research was found on best practices for reducing errors and improving infusion pump use through workflow and process changes, as well as education and training. Four studies reported medication administration errors, procedural errors, or deviations from hospital policy as clinical outcomes of workflow or process changes. Mixed results were found examining process outcomes related to pump handling. Education on the correct use of smart pumps was found to decrease medication errors and adverse drug events, and 2 studies found an increase in nurses’ adherence to using the medication safety software library as a result of education.ConclusionsStandardization of process and integration of technology and workflows were found as facilitators. Type and content of education provided were identified as facilitators, whereas time and energy constraints on nurse educators can be barriers to implementing large hospital-wide education programs.

Objective assessment of stored blood quality by deep learning

Stored red blood cells (RBCs) are needed for life-saving blood transfusions, but they undergo continuous degradation. RBC storage lesions are often assessed by microscopic examination or biochemical and biophysical assays, which are complex, time-consuming, and destructive to fragile cells. Here we demonstrate the use of label-free imaging flow cytometry and deep learning to characterize RBC lesions. Using brightfield images, a trained neural network achieved 76.7% agreement with experts in classifying seven clinically relevant RBC morphologies associated with storage lesions, comparable to 82.5% agreement between different experts. Given that human observation and classification may not optimally discern RBC quality, we went further and eliminated subjective human annotation in the training step by training a weakly supervised neural network using only storage duration times. The feature space extracted by this network revealed a chronological progression of morphological changes that better predicted blood quality, as measured by physiological hemolytic assay readouts, than the conventional expert-assessed morphology classification system. With further training and clinical testing across multiple sites, protocols, and instruments, deep learning and label-free imaging flow cytometry might be used to routinely and objectively assess RBC storage lesions. This would automate a complex protocol, minimize laboratory sample handling and preparation, and reduce the impact of procedural errors and discrepancies between facilities and blood donors. The chronology-based machine-learning approach may also improve upon humans' assessment of morphological changes in other biomedically important progressions, such as differentiation and metastasis.

European expert consensus on a structured approach to training robotic-assisted low anterior resection using performance metrics.

AimThe aim was to develop and operationally define ‘performance metrics’ that characterize a reference approach to robotic‐assisted low anterior resection (RA‐LAR) and to obtain face and content validity through a consensus meeting.MethodThree senior colorectal surgeons with robotic experience and a senior behavioural scientist formed the Metrics Group. We used published guidelines, training materials, manufacturers’ instructions and unedited videos of RA‐LAR to deconstruct the operation into defined, measurable components – performance metrics (i.e. procedure phases, steps, errors and critical errors). The performance metrics were then subjected to detailed critique by 18 expert colorectal surgeons in a modified Delphi process.ResultsPerformance metrics for RA‐LAR had 15 procedure phases, 128 steps, 89 errors and 117 critical errors in women, 88 errors and 118 critical errors in men. After the modified Delphi process the final performance metrics consisted of 14 procedure phases, 129 steps, 88 errors and 115 critical errors in women, 87 errors and 116 critical errors in men. After discussion by the Delphi panel, all procedure phases received unanimous consensus apart from phase I (patient positioning and preparation, 83%) and phase IV (docking, 94%).ConclusionA robotic rectal operation can be broken down into procedure phases, steps, with errors and critical errors, known as performance metrics. The face and content of these metrics have been validated by a large group of expert robotic colorectal surgeons from Europe. We consider the metrics essential for the development of a structured training curriculum and standardized procedural assessment for RA‐LAR.

Human error analysis of the Montara well blowout

AbstractThe 2009 blowout from the Montara wellhead resulted the total loss of the West Atlas drilling rig and caused massive ecological damage in the Timor Sea of Australia. The incident preceded the 2010 Macondo Deepwater Horizon blowout and shared many parallels. An analysis is performed to assess the Montara incident and finds it stemmed from a series of human errors including, but not limited to, miscalculations, procedural errors, hasty decision making, and failure to follow the American Petroleum Institute Recommended Practices 75 on drilling mud circulation. Twelve specific errors were identified and classified into eight categories. The results show that 10 of the 12 errors were latent errors preceded by the 2004 relaxation of the Australian Government's off‐shore drilling industry regulations. Following industry guidelines, best practice procedures, and safe work practices are crucial to avoiding a well disaster and these were not a key aspect of the Montara wellhead operations; ultimately, safety was not a top priority.

Are students having trouble solving problems polyhedron?

The ability to solve problems is not only needed in school learning, but also to solve problems in daily life. One of the problems that cannot be separated from daily life is related to space objects such as tables, cabinets, bottles, balls, houses, and others. Mathematics is a lesson’s school that addresses these problems, especially regarding (to) polyhedrons. The purpose of this study is to describe the difficulties of students in solving problems related to polyhedrons. The difficulties are classified based on Newman’s Error Procedure (NEP). The research method used is a case study. The respondents of this study were middle school students of class IX (ninth grade of middle school). Data collection is done through tests and interviews. Validity is measured based on the Aiken index with a score of 0.82 which mean it is very valid. The difficulties are analyzed descriptively by observing the students’ errors in answering test questions. The results showed that about 8% of students had difficulty in reading error, 13% of students had difficulty in comprehension error, 21% of students had difficulty in transformation error, 49% of students had difficulty process skills error, and 71% of students had difficulty in encode error. It is known several factors that cause these errors so that some solutions can be obtained by the teacher to overcome these errors.

A comparison of area level and unit level small area models in the presence of linkage errors

Abstract In Official Statistics, interest in data integration has grown enormously, but the effect of integration procedures on statistical analysis has not yet been sufficiently developed. Data integration is not an error-free procedure and linkage errors, as false links and missed links can invalidate standard estimates. Recently, increasing attention has been paid to the effect of linkage errors on the statistical analyses and on statistical predictions. Recently, methods to adjust the unit level small area estimators for linkage errors have been proposed when the domains are correctly specified. In this paper we compare the na¨ıve and the adjusted unit level estimators with the area level estimators that are not affected by the linkage errors. The comparison encourages the use of the adjusted unit level estimator.

In the matter of some issues on the notice of accusation according to criminal procedural law of Ukraine

The author examines the problematic issues of the essence of the notification of suspicion, its concept, meaning, which scientists interpret as: procedural activity, the meaning of which is the preparation by the investigator or prosecutor of a written notice of the suspicion and its delivery to the person in accordance with Art. art. 276-279 of the Criminal Procedural Code of Ukraine; procedural decision; procedural action; institute of criminal procedural law; pre-trial stage and the form of notification; pre-trial investigation stage; the first stage of formation of the state prosecution; the primary form of indictment against a specific person; commencement of the prosecution function. The ambiguous legislative regulation of the institution of notification of suspicion is considered, in particular, the absence of specific normative consolidation of the basic concepts of the institution of notification of suspicion and contradiction of the articles of the Criminal Procedural Code of Ukraine (Article 177 and Article 276), and chapter 22 of the Criminal Procedural Code of Ukraine, entitled “Notification of suspicion” regarding the connection of the procedural activity from the notification of suspicion with the array of the procedural actions of the investigator and / or prosecutor, the meaning of which is to establish legal and factual grounds for notification of suspicion (Art. 276), the drafting of a written procedural document (notice of suspicion) (art. 277) and its delivery to a person (art. 278). Attention is drawn to certain aspects when giving notice of suspicion and explaining rights to a person, as well as to typical procedural errors when notifying a person of suspicion, namely, acquisition of the procedural status of a suspect from the moment of actual delivery of mail with notification of suspicion; the formal explanation to suspects of the scope of their rights, the possibility of abuse by investigators and prosecutors of the right to apply a special procedure for notifying a person of suspicion. Key words:notice of accusation (suspicion notification), legal and factual grounds for suspicion notification, procedure for suspicion notification, notice of accusation submission, explaining rights to the suspect, notification delivery, typical procedural errors.