Event Recording System Research Articles

Evaluating patient safety: Analysis of adverse events in hospitals in Hidalgo

This descriptive observational study analyzes adverse events in public hospitals in Hidalgo between 2013 and 2021. The main objective is to understand patient safety at the local level using data from the Adverse Event Recording System. Data from 1,830 surveys from 14 hospitals were collected, focusing on sociodemographic, clinical, and hospital service variables. The results indicate a higher prevalence of adverse events in women (59.78%) and in the age group of 21 to 30 years. The most common places of occurrence were Internal Medicine and Hospitalization, mainly during the morning shift. The most frequent incidents were medication-related, falls, and infections, with a majority classified as 'no harm'. Patient characteristics and the application of protocols were identified as factors most commonly present in adverse events. However, only 2.02% of the events underwent a root cause analysis. The study highlights the need to develop specific strategies for prevention and reporting, emphasizing continuous education of medical staff and the strengthening of hospital policies, and the consolidation of information on adverse events for future research.

Enhancing Security and Accountability in Autonomous Vehicles through Robust Speaker Identification and Blockchain-Based Event Recording

As the deployment of Autonomous Vehicles (AVs) gains momentum, ensuring both security and accountability becomes paramount. This paper proposes a comprehensive approach to address these concerns. With the increasing importance of speaker identification, our first contribution lies in implementing a robust mechanism for identifying authorized users within AVs, enhancing security. To counter the threat of voice spoofing, an ensemble-based approach leveraging speaker verification techniques is presented, ensuring the authenticity of user commands. Furthermore, in scenarios of accidents involving AVs, the need for accurate accountability and liability allocation arises. To address this, we introduce a novel application of blockchain technology, enabling an event recording system that ensures transparent and tamper-proof records. The proposed system enhances AV security and establishes a framework for reliable accident investigation using speakers’ records. In addition, this paper presents an innovative concept where vehicles act as impartial judges during accidents, utilizing location-based identification. Results show the viability of the proposed solution for accident investigation and analysis.

A Web-Based Tool to Report Adverse Drug Reactions by Community Pharmacists in Australia: Usability Testing Study.

Adverse drug reactions (ADRs) are unintended and harmful events associated with medication use. Despite their significance in postmarketing surveillance, quality improvement, and drug safety research, ADRs are vastly underreported. Enhanced digital-based communication of ADR information to regulators and among care providers could significantly improve patient safety. This paper presents a usability evaluation of the commercially available GuildCare Adverse Event Recording system, a web-based ADR reporting system widely used by community pharmacists (CPs) in Australia. We developed a structured interview protocol encompassing remote observation, think-aloud moderating techniques, and retrospective questioning to gauge the overall user experience, complemented by the System Usability Scale (SUS) assessment. Thematic analysis was used to analyze field notes from the interviews. A total of 7 CPs participated in the study, who perceived the system to have above-average usability (SUS score of 68.57). Nonetheless, the structured approach to usability testing unveiled specific functional and user interpretation issues, such as unnecessary information, lack of system clarity, and redundant data fields-critical insights not captured by the SUS results. Design elements like drop-down menus, free-text entry, checkboxes, and prefilled or auto-populated data fields were perceived as useful for enhancing system navigation and facilitating ADR reporting. The user-centric design of technology solutions, like the one discussed herein, is crucial to meeting CPs' information needs and ensuring effective ADR reporting. Developers should adopt a structured approach to usability testing during the developmental phase to address identified issues comprehensively. Such a methodological approach may promote the adoption of ADR reporting systems by CPs and ultimately enhance patient safety.

Effects of the dopamine depleting agent tetrabenazine on detailed temporal parameters of effort-related choice responding.

The dopamine-depleting agent tetrabenazine alters effort-based choice, suppressing food-reinforced behaviors with high response requirements, while increasing selection of low-cost options. In the present experiments, rats were tested on a concurrent fixed ratio 5/chow feeding choice task, in which high-carbohydrate Bio-serv pellets reinforced lever pressing and lab chow was concurrently available. Detailed timing of lever pressing was monitored with an event recording system, and the temporal characteristics of operant behavior seen after 1.0 mg/kg tetrabenazine or vehicle injections were analyzed. Tetrabenazine shifted choice, decreasing lever pressing but increasing chow intake. There was a small effect on the interresponse-time distribution within ratios, but marked increases in the total duration of pauses in responding. The postreinforcement-pause (PRP) distribution was bimodal, but tetrabenazine did not increase the duration of PRPs. Tetrabenazine increased time feeding and duration and number of feeding bouts, but did not affect feeding rate or total time spent lever pressing for pellets and consuming chow. Thus, TBZ appears to predominantly affect the relative allocation of lever pressing versus chow, with little alteration in consummatory motor acts involved in chow intake. Tetrabenazine is used to model motivational symptoms in psychopathology, and these effects in rats could have implications for psychiatric research.

Time-Resolved Neutron Diffraction During Engineering Processes Using Event Recording System at J-PARC

Time-Resolved Neutron Diffraction During Engineering Processes Using Event Recording System at J-PARC

Self-initiations in young children with autism during Pivotal Response Treatment with and without robot assistance.

The initiation of social interaction is often defined as a core deficit of autism spectrum disorder. Optimizing these self-initiations is therefore a key component of Pivotal Response Treatment, an established intervention for children with autism spectrum disorder. However, little is known about the development of self-initiations during intervention and whether this development can be facilitated by robot assistance within Pivotal Response Treatment. The aim of this study was to (1) investigate the effect of Pivotal Response Treatment and robot-assisted Pivotal Response Treatment on self-initiations (functional and social) of young children with autism spectrum disorder over the course of intervention and (2) explore the relation between development in self-initiations and additional gains in general social-communicative skills. Forty-four children with autism spectrum disorder (aged 3-8 years) were included in this study. Self-initiations were assessed during parent-child interaction videos of therapy sessions and coded by raters who did not know which treatment (Pivotal Response Treatment or robot-assisted Pivotal Response Treatment) the child received. General social-communicative skills were assessed before start of the treatment, after 10 and 20 weeks of intervention and 3 months after the treatment was finalized. Results showed that self-initiations increased in both treatment groups, with the largest improvements in functional self-initiations in the group that received robot-assisted Pivotal Response Treatment. Increased self-initiations were related to higher parent-rated social awareness 3 months after finalizing the treatment.

Proof-of-Event Recording System for Autonomous Vehicles: A Blockchain-Based Solution

Autonomous vehicles are capable of sensing their environment and navigating without any human inputs. However, when autonomous vehicles are involved in accidents between themselves or with human subjects, liability must be indubitably decided based on accident forensics. This paper proposes a blockchain-inspired event recording system for autonomous vehicles. Specifically, we design the mechanism of “Proof-of-Event” with a dynamic federation consensus to achieve indisputable accident forensics by providing trustable and verifiable event information. We propose a dynamic federation consensus scheme to verify and confirm the new block of event data in an efficient way without any central authority. We conduct numerical analyses and prototyped experiments based on the proposed fast leader election algorithm and the Hyperledger Fabric blockchain network. The results show that our system is effective and feasible in generating and storing accident records in blockchain-based vehicular networks. The security capability of the proposed scheme is also discussed against multiple threats and attack scenarios.

The Effects of Language Intervention Using Manual Signing on Utterances of Young Children with Language Developmental Delay

본 연구는 손짓기호를 활용한 언어중재가 언어발달지체 유아의 시작발화, 반응발화, 명료한 발화에 미치는 효과를 알아보고자 하였다. 연구는 대상자간 중다기초선 설계를 통해 기초선, 중재, 유지 단계로 진행되었다. 손짓기호를 활용한 언어중재는 교사와 유아 간 놀이 상황에서 목표어휘에 해당하는 손짓기호와 말을 모방 훈련하는 과정과 모방훈련 없이 시간지연, 손짓기호 단서 제공, 우발교수 환경구성 등 자연적인 언어 중재 전략을 통해 자발적인 발화를 유도하는 과정으로 구성되었다. 교사와 유아 간의 자연스러운 놀이 맥락에서 이루어지는 의사소통 중 유아의 자발적인 시작발화, 반응발화, 조음이 명료한 발화를 수집하여 각각의 어절 수를 측정하였다. 연구 결과 손짓기호를 활용한 언어중재는 언어발달지체 유아의 시작발화, 반응발화, 명료한 발화를 향상시키는데 효과가 있었다. 연구 결과에 근거하여 언어발달지체 유아의 발화 촉진에 긍정적인 영향을 줄 수 있는 손짓기호를 활용한 언어중재의 효율성에 대해 논의하였다.The purpose of this study was to investigate the effects of language intervention using manual signing on utterances of 2 young children with language developmental delay. Utterance was operationally defined as initiating utterance, responding utterance, and intelligible utterance. The study used multiple baseline across subjects design: initial baseline, intervention, and maintenance condition. Intervention was implemented twice per week, each session was proceeded for 30 minute. Language intervention using manual signing was composed of the two phase: manual signing and utterance imitation training and the naturalistic language intervention. The utterances of each child was collected using the event recording system. Then the number of words of initiating utterances, correct responding utterances, and intelligible utterances two observer had agreed were calculated. The results of this study were as follows. The language intervention using manual signing increased the number of words of initiating, responding, and intelligible utterances of the 2 young children with language developmental delay. The effects were maintained after the termination of intervention. This indicates that language intervention using manual signing would be used as an effective intervention for utterance improvement of young children with language developmental delay having hand imitation skills.

비장애 형제와 함께하는 협동놀이가 아스퍼거 증후군 아동의 사회적 상호작용에 미치는 영향: 사례연구*

The purpose of this study was to examine effects of Cooperative Play Intervention on social interaction of children with Asperger Syndrome. For this study, one elementary student with Asperger Syndrome were selected and A-B design has been used. Initially, baseline data were collected for social initiations and responses. During intervention, evaluation was made for 15-minute observation session using event recording system and anecdotal records. The intervention was made after evaluation. The intervention was practiced in home-setting with non-disabled children. Follow-up data were collected 2 weeks after withdrawal of the intervention in the same setting as the baseline condition. The results of in this study, Cooperative Play Intervention is effective for increasing social interactions of Asperger Syndrome and also for maintaining.

Use of a Patient-activated Event Recording System in a Patient with Infrequent Palpitations

Holter monitoring is usually limited to a 24-hour period. However, this duration may be inadequate in cases where palpitations are infrequent. A 17-year-old male patient with infrequent paroxysmal palpitations was diagnosed with paroxysmal supraventricular tachycardia after he was monitored with a patient-activated event recording system. We observed that this device can provide useful diagnostic information in the outpatient clinical setting.

Use of a Patient-Activated Event Recording System in Patients with Tachycardic Palpitations: How Long to Follow Up?

Palpitations are a common symptom causing patients to consult a cardiologist, yet diagnosing a potential cardiac origin can be difficult. In patients with a nondiagnostic Holter-ECG, external loop-recorders are an additional tool to diagnose the clinical arrhythmia in these patients. The aim of our study was to evaluate the additional value of an external, patient-activated loop recorder and to determine the optimal time of follow up needed to achieve a symptom-rhythm correlation with the device. A total of 1404 patients presented to our outpatient clinic between November 2011 and November 2014 for first time evaluation of symptomatic arrhythmias. Of a total of 91 patients were included (age 43.6±18.1; 69.2% female) in the study. All patients presented with tachycardic palpitations and a 48-hour Holter-ECG that did not detect relevant arrhythmias. All patients were given a "leadless" patient-activated event-recording system and regular follow-up visits were scheduled after 3, 6, and 12 months. Within a maximum follow-up time of 1 year, 72 patients (79.1%) recorded at least one ECG with the device. Of the recorded ECGs, 51% were recorded within the first week after the device was handed out. This figure rises to 80% and 93% after 1 and 2 months. The last recording was after 174 days. For patients with tachycardic palpitations, the external "leadess" event recorders are effective in achieving a symptom-rhythm correlation. A follow up of 2 months will suffice to establish a diagnosis in a large majority of this patient group.

Utility of wireless ECG event recording system in children

AimEvent recorders have been widely used for diagnosis of cardiac rhythm disorders in patients who describe infrequent symptoms, which may be attributed to arrhythmias. These systems may helpful in patients with negative conventional cardiac tests such as ECG, Holter monitoring and exercise test. We reported our results with wireless event recording in a small patient group. MethodsMedical records of eight children who suffered from infrequent palpitations with negative tests, received V-patch event recording system between August 2011 and March 2012 were reviewed retrospectively. The mean age of the patients was 10.7. Two patients had undergone invasive electrophysiological study and had normal results. ResultsTwo patients removed from study, remaining six patients were followed for 23.3 ± 6.59 days. Two patients showed narrow QRS complex tachycardia in the first week and antiarrhythmic drug therapy was initiated. In one of them with narrow QRS tachycardia previous EPS was negative. Four patients showed physiologic sinus tachycardia during symptoms and referred to other clinics or discharged from cardiology follow-up. ConclusionV-patch wireless event recorder system might be a more preferable method in patients with arrhythmia symptoms and negative noninvasive tests.

Improving linear accelerator service response with a real- time electronic event reporting system.

To track linear accelerator performance issues, an online event recording system was developed in‐house for use by therapists and physicists to log the details of technical problems arising on our institution's four linear accelerators. In use since October 2010, the system was designed so that all clinical physicists would receive email notification when an event was logged. Starting in October 2012, we initiated a pilot project in collaboration with our linear accelerator vendor to explore a new model of service and support, in which event notifications were also sent electronically directly to dedicated engineers at the vendor's technical help desk, who then initiated a response to technical issues. Previously, technical issues were reported by telephone to the vendor's call center, which then disseminated information and coordinated a response with the Technical Support help desk and local service engineers. The purpose of this work was to investigate the improvements to clinical operations resulting from this new service model. The new and old service models were quantitatively compared by reviewing event logs and the oncology information system database in the nine months prior to and after initiation of the project. Here, we focus on events that resulted in an inoperative linear accelerator (“down” machine). Machine downtime, vendor response time, treatment cancellations, and event resolution were evaluated and compared over two equivalent time periods. In 389 clinical days, there were 119 machine‐down events: 59 events before and 60 after introduction of the new model. In the new model, median time to service response decreased from 45 to 8 min, service engineer dispatch time decreased 44%, downtime per event decreased from 45 to 20 min, and treatment cancellations decreased 68%. The decreased vendor response time and reduced number of on‐site visits by a service engineer resulted in decreased downtime and decreased patient treatment cancellations.PACS numbers: 87.56.bd, 87.55.Qr

Utilization of an Event-Recording System for Neutron Diffraction Experiments

We present effectivity of an event-recording system in neutron diffraction experiments at the Engineering Materials Diffractometer TAKUMI at the Materials and Life Science Experimental Facility in J-PARC. We developed an event-recording system for recording information of neutron generation and detection and sample environmental conditions like load, strain, etc. as events with synchronized timing tag across whole system, and developed a software to handle the event data. It gave us several advantages by allowing us flexible data reduction depending on users’ purposes, especially for time resolved experiments. We demonstrated in situ neutron diffraction measurements using these new recording system and software to show the advantages. These new system and software are very attractive to be applied for measurements that need stroboscopic data collection such as fatigue tests.

Comparison of the patient-activated event recording system vs. traditional 24 h Holter electrocardiography in individuals with paroxysmal palpitations or dizziness

Electrocardiographic documentation of symptomatic episodes of palpitations by means of traditional methods such as 24 h Holter monitoring (HM) or loop recorders is challenging. Patient-activated electrocardiography (ECG) recorders have been proved to be a useful tool in the diagnosis of arrhythmias in these patients. However, no comparison studies between the two techniques have been conducted. The aim of this study was to compare the diagnostic value of Holter ECG and a patient-activated event recorder (OMRON portable HeartScan ECG Monitor(®)) (HeartScan) in the detection of arrhythmias in patients with paroxysmal palpitations or dizziness suggestive of cardiac arrhythmias. Patients with paroxysmal palpitations or dizziness were eligible for this study. All patients underwent an HM for 24 h and a 15-day HeartScan after the HM. Six hundred and twenty-five patients (48% male, mean age: 37 ± 11 years) were included in the study. All patients present with normal heart structure, normal baseline 12-lead ECG, and normal echocardiogram. Indications for ECG monitoring were palpitations in 577 patients (92.3%) and dizziness in 48 (7.7%). Holter monitoring offered a clinical diagnosis in 11 patients (1.8%). Conversely, HeartScan diagnosed the clinical arrhythmia in 558 individuals (89%). Detection of symptoms-related arrhythmias by means of HeartScan was significantly higher when compared with HM (P < 0.01). The studied system proved to be an efficient event recorder providing the diagnosis of the clinical arrhythmia in 89% of patients with paroxysmal palpitations or dizziness. Further studies are needed to confirm our results.

Medication events on a tertiary neurology inpatient service

This study aimed to determine the prevalence and attributes of medication events in a tertiary inpatient neurology setting. These findings were compared with the results of a physician survey designed to assess general knowledge of medication events. We reviewed all medication events reported through an established voluntary event recording system for adult neurology inpatients at a tertiary referral center over a 2year period. An electronic survey was sent to all neurology residents and hospital staff regarding medication events. One hundred and forty-three medication events were reported, for a rate of 8.6 events per 1000 patient-days. The medication event rate was comparable to published rates on medicine services. There was no evidence of events being more prevalent at the beginning of the academic year or on nights. One hundred and seventeen events (81.8%) reached the patient, but most (92.7%, 108/117) did not result in harm. The most common medication types involved were anticoagulants (24 events, 16.8%), anticonvulsants (17 events, 11.9%), and antibiotics (16 events, 11.2%). Nurses were involved in reporting 133 events (93%), while physicians were involved in reporting 20 events (14%). Physicians completed the survey at a rate of 60.8% (48/79). There were notable differences between physician presumptions as to medication event attributes and actual results. No trend referable to time of year or day was identified, which contrasted with physician beliefs in our survey. Nursing staff reported the majority of events.

SU-E-P-05: A New Delivery Model for Linear Accelerator Support and Service

Purpose: A new model of service and support has been developed between our institution and a linear accelerator vendor. Previously, a user would report machine breakdown events verbally by telephone to a dispatch center, which then coordinated repair actions with the technical helpdesk and local service engineer. In the new model, events are reported electronically directly to the vendor technical helpdesk, who can then contact the user immediately to coordinate a response. The purpose of this work is to report on a new model for vendor/institution collaboration to improve clinical operations. Methods: We developed a new on-line event recording system that connected our clinic events directly to the linear accelerator vendor. Between February 2012 and 2013, our institutional electronic quality reporting database was reviewed. A machine down event was defined as a technical problem with the linear accelerator that interrupted, prevented, or required rescheduling or cancellation of patient treatments. Machine down time, vendor support response time, and whether the event was resolved by a service engineer visit or by physicists liaising with the technical helpdesk, were recorded. Results: Over 259 clinical days, there were 76 machine down events, with 45 before introduction of the new service model and 31 after. Under the new model, the average time for service response decreased by 92%, from 128 to 10 minutes and the number of times a service engineer had to be dispatched decreased by 70%. The down time per event decreased by 47% from 135 minutes to 71 minutes. Treatment cancellations or rescheduling decreased by 54%. Conclusion: A new model of linear accelerator support and service delivery was implemented and was found to decrease vendor response time and reduce the number of on-site visits required by service engineers. These performance gains resulted in decreased machine downtime and decreased patient treatment cancellations. The work was undertaken in cooperation with Varian Medical Systems.

The excitation system of 727.5 MVA synchronous generator of the unit B1 in TPP 'Nikola Tesla B'

This paper presents a technical solution for the replacement of the excitation system of the unit B1 in TPP 'Nikola Tesla B' as a part of the maintenance service in 2012. Since the generators of TPP 'Nikola Tesla B' have the greatest power in the power system of Serbia, it was necessary to achieve high reliability of the excitation system so that the process of producing electricity is not endangered Considering this, the implemented excitation system uses modern technology with redundancy both in the power and control blocks, which resulted in an increase in the hot reserve by 100%. In addition, it was necessary to adjust the excitation system to increased generator power and performance from 618MW to 667.5MW. In this paper, the main parameters of the excitation system are given: the power, the excitation system control, the thyristor ignition system, the event recorder system, the digital relay protection, as well as the measuring and signaling functions.

Recent Developments of Instruments in a Spallation Neutron Source at J-PARC and Those Prospects in the Future

The paper describes developments of neutron scattering instruments in J-PARC neutron facility, which is a short pulse spallation source operated at a repetition rate 25 Hz and has a proton power 1 MW. New concept has been adopted to utilize high intensity coupled moderator even for a high resolution inelastic scattering instruments by taking a pulse shaping chopper system. Advanced technique has been also realized by taking an ability of event-recording system altogether with an improvement of a chopper system, realizing multi-Ei method. The paper also touches upon a general design concept for diffractometers in accordance with the source characteristics.

Medication Events on a Tertiary Neurology Inpatient Service (P07.239)

Objective: To describe medication events occurring on neurological hospital services. Background Medication events are common in hospitalized patients. Relatively little is known about the characteristics of medication events on neurology inpatient services. Design/Methods: Medication events reported on inpatient neurology services (general neurology, epilepsy monitoring unit, cerebrovascular service, and neurological ICU) were reviewed from January 1, 2009 through December 31, 2010 in a 1,265-bed tertiary care center. Data collection was through a pre-established institutional voluntary event recording system. Reportable events included any event that was an undesired occurrence that caused or had the potential to cause injury. Results: 143 medication events were reported, for a rate of 8.6 events per 1000 patient days. There were no trends associated with time of day or month of the year. Of these, 118 (82.5%) reached the patient; 103 (72%) did not require intervention. The most common medication types involved were anticoagulants (24 events, 16.8%), anticonvulsants (17 events, 11.9%), and antibiotics (16 events, 11.2%). The most common types of events were medication omission (27 events, 18.9%) and wrong medication dose/rate (26 events, 18.2%). The most common step in which an event occurred was administration (77 events, 53.8%). Nurses were involved in reporting 133 events (93%), while physicians were involved in reporting 20 events (14%). Conclusions: Medication events were not uncommon on our neurology inpatient services, and most commonly involved anticoagulants, anticonvulsants and antibiotics. No trends referable to time of year or day were identified to suggest an association with the academic calendar or call coverage. Nursing staff reported the majority of events, suggesting a stronger culture of event reporting in non-physician providers on out unit. Disclosure: Dr. Williams has nothing to disclose. Dr. Sweeney has nothing to disclose. Dr. Britton has received personal compensation for activities with Cyberonics, Inc. as a consultant.