New Types Of Errors Research Articles

Implementation of Computerized Prescriber Order Entry Systems: A Review of Impacts, Barriers, and Facilitators.

This review evaluated the impact of a digitized computerized prescriber order entry (CPOE) system and described barriers and facilitators for introducing a digitized system. A systematic literature search was conducted in PubMed, Medline, and CINAHL using keywords. Articles in English during the last 10 years were included. Study selection was presented using a PRISMA flow diagram. Forty-eight studies were included. Data from the articles were presented to address each of the three objectives. CPOE systems improved the quality of care provided but also introduced new types of errors. Facilitating factors for implementation included leadership, stakeholder engagement, training, and user-centered design. Inadequate training, software design, changes in workload, and workflow disruptions were identified as barriers. Recommendations for implementation included dedicated training of users, user-centered design, a backup for system downtimes, and stakeholder engagement. Application of knowledge of the facilitators and barriers for the introduction of a CPOE system supports this change-management process within the specific context and augurs for more successful implementation.

A Closed Burst Error Correcting Codes Cantor Fractal Approach

The nature of the errors depends on the behaviour of channel, there is a need to study different types of error pattern. This paper explores the new type of error called closed burst and obtained the possibilities of the existence of two types of block wise burst error correcting codes of length 3^N and 3N respectively with cantor fractal approach over GF(2). The code envisaged are meant to correct all the closed bursts of length b_i in the i^thiteration in the first and last sub-blocks of equal length l_i.

Equivalence Analysis of Cascade Control for a Class of Cascade Integral Systems

A class of generalized proportional-integral-derivative (PID) control with feedforward compensation (FFC) is obtained for a class of cascade integral systems by equivalence analysis of the cascade control and such the analysis is obtained by using the information of the model and outermost loop feedback. Firstly, a new type of error related to the traditional error such as proportional (P) or proportional integral (PI) is given. Secondly, by analyzing cascade control for a class of ideal cascade integral systems, the generalized PID control with FFC is presented based on the proposed new type of error. Then, the generalized PID control with FFC is extended to a class of non-ideal cascade integral systems to reduce the number of feedback loop and sensors. Finally, the simulation results of the speed/position servo system of direct current motor are given to verify the theoretical analysis results.

Health technology, quality and safety in a learning health system.

Health technology quality and safety is an important issue for health informatics (i.e. digital health) professionals. Health technologies have been used to (1) collect data that can be analyzed to improve the quality and safety of healthcare activities and (2) re-engineer and/or automate error-prone processes. Health technologies are also able to introduce new types of errors (i.e. technology-induced errors) and have been implicated in propagating errors across digital health ecosystems. To develop a learning health system, health technologies need to be considered in terms of how they can improve the quality and safety of health activities traditionally carried out by humans (patients and health professionals) and also how the technology's quality and safety can be improved. This article outlines how this can be done by integrating evidence from health informatics research into practice using a learning health systems approach.

Automated Dispensing Cabinet Overrides—An Evaluation of Necessity in a Pediatric Emergency Department

ObjectiveAutomated dispensing cabinets, or ADCs, are often used at health care facilities to aid in the medication-use process. Although ADCs minimize certain medication errors, they introduce a new type of error involving overrides. Although helpful when used appropriately in emergencies, overrides bypass pharmacist verification and increase potential for patient harm through drug-drug interactions, medication allergies, inappropriate dosing, and more. The purpose of this study was to evaluate automated dispensing cabinets override pulls in a pediatric hospital’s emergency department. The authors sought to discover whether overridden medications were being administered before verification (indicating it was needed emergently, thus justifying override) or after verification (indicating the override did not result in quicker administration and/or the medication was not emergent). MethodsThis was a retrospective, observational study. Data were collected from electronic health record reports from a 343-bed pediatric hospital’s emergency department from October 13, 2019, to December 22, 2019. ResultsA total of 445 override pulls were identified during this time, and after data analysis, 99 override pulls remained in the data set. Overall, time from input of prescription into the electronic medical record to medication override was approximately 4 minutes. Pharmacist verification also took a median of four minutes after prescription input. However, administration took twice as long, at 8 minutes. On average, pharmacist verification occurred 4 minutes before medication administration. ConclusionThis research from a pediatric emergency department suggests that most situations did not require an immediate administration, and perhaps an override was unnecessary and could have been avoided.

Classification and Fast Few-Shot Learning of Steel Surface Defects with Randomized Network

Quality inspection is inevitable in the steel industry so there are already benchmark datasets for the visual inspection of steel surface defects. In our work, we show, contrary to previous recent articles, that a generic state-of-art deep neural network is capable of almost-perfect classification of defects of two popular benchmark datasets. However, in real-life applications new types of errors can always appear, thus incremental learning, based on very few example shots, is challenging. In our article, we address the problems of the low number of available shots of new classes, the catastrophic forgetting of known information when tuning for new artifacts, and the long training time required for re-training or fine-tuning existing models. In the proposed new architecture we combine EfficientNet deep neural networks with randomized classifiers to aim for an efficient solution for these demanding problems. The classification outperforms all other known approaches, with an accuracy 100% or almost 100%, on the two datasets with the off-the-shelf network. The proposed few-shot learning approach shows considerably higher accuracy at a low number of shots than the different methods under testing, while its speed is significantly (at least 10 times) higher than its competitors. According to these results, the classification and few-shot learning of steel surface defects can be solved more efficiently than was possible before.

Restarting Frank–Wolfe: Faster Rates under Hölderian Error Bounds

Conditional gradient algorithms (aka Frank–Wolfe algorithms) form a classical set of methods for constrained smooth convex minimization due to their simplicity, the absence of projection steps, and competitive numerical performance. While the vanilla Frank–Wolfe algorithm only ensures a worst-case rate of $${\mathcal {O}}(1/\epsilon )$$ , various recent results have shown that for strongly convex functions on polytopes, the method can be slightly modified to achieve linear convergence. However, this still leaves a huge gap between sublinear $${\mathcal {O}}(1/\epsilon )$$ convergence and linear $${\mathcal {O}}(\log 1/\epsilon )$$ convergence to reach an $$\epsilon $$ -approximate solution. Here, we present a new variant of conditional gradient algorithms that can dynamically adapt to the function’s geometric properties using restarts and smoothly interpolates between the sublinear and linear regimes. These interpolated convergence rates are obtained when the optimization problem satisfies a new type of error bounds, which we call strong Wolfe primal bounds. They combine geometric information on the constraint set with Hölderian error bounds on the objective function.

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

IntroductionAdvancements in technology and processes are designed to bring improvement. However, this is often achieved in parallel with increases in complexity, simultaneously presenting opportunities for new types of errors. This study aims to contextualise the impact of internal departmental changes upon radiation incidents and near misses recorded.MethodsA timeline of events and a comprehensive incident categorisation system were applied to all radiation incidents and near misses recorded at the Princess Alexandra Hospital Radiation Oncology department from 2003 to 2019, inclusive. Descriptive statistics were performed to identify the type and number of incidents reported during the time period in relation to potential changes within the department, with a focus on the implementation of an electronic environment.ResultsOver the seventeen‐year period, 157 incidents and 76 near misses were reported. The majority of incidents were classified as ‘procedural’ (78%), with ‘treatment’ being both the highest point of error and point of detection (49% and 85%, respectively).The largest number of incidents and near misses were reported in 2018 (n = 39) which was also a year that experienced the largest number of departmental changes (n = 16), including the move to a completely electronic planning process.ConclusionsChanges within the department were followed by an increasing number of reported incidents. Proactive measures should be undertaken prior to the implementation of major changes within the department to aid in the minimisation of incident occurrence.

Analysing errors in single-molecule localisation microscopy.

In single molecule localisation microscopy (SMLM) a super-resolution image of the distribution of fluorophores in the sample is built up from the localised positions of many individual molecules. It has become widely used due to its experimental simplicity and the high resolution that can be achieved. However, the factors which limit resolution in a reconstructed image, and the artefacts which can be present, are completely different to those present in standard fluorescent microscopy techniques. Artefacts may be difficult for users to identify, particularly as they can cause images to appear falsely sharp, an effect called artificial sharpening. Here we discuss the different sources of error and bias in SMLM, and the methods available for avoiding or detecting them.

Transport safety and human factors in the era of automation: What can transport modes learn from each other?

One of the main aims of introducing automation in transport is to improve safety by reducing or eliminating human errors; it is often argued however that this may induce new types of errors. There is different level of maturity with automation in different transport modes (road, aviation, maritime and rail), however no systematic research has been conducted on the lessons learned in different sectors, so that they can be exploited for the design of safer automated systems. The aim of this paper is to review the impact of key human factors on the safety of automated transport systems, with focus on relevant experiences from different transport sectors. A systematic literature review is carried out on the following topics: the level of trust in automation – in particular the impact of mis-aligned trust, i.e. mistrust vs overreliance, the resulting impact on operator situation awareness (SA), the implications for takeover control from machine to human, and the role of experience and training on using automated transport systems. The results revealed several areas where experiences from the aviation and road domain can be transferable to other sectors. Experiences from maritime and rail transport, although limited, tend to confirm the general patterns. Remarkably, in the road sector where higher levels of automation are only recently introduced, there are clearer and more quantitative approaches to human factors, while other sectors focus only on mental modes. Other sectors could use similar approaches to define their own context-specific metrics. The paper makes a synthesis of key messages on automation safety in different transport sectors, and presents an assessment of their transferability.

The Impact of Robotic-Assisted Surgery on Team Performance: A Systematic Mixed Studies Review.

The aim of this study is to describe the impact of robotic-assisted surgery on team performance in the operating room. The introduction of surgical robots has improved the technical performance of surgical procedures but has also contributed to unexpected interactions in surgical teams, leading to new types of errors. A systematic literature search of Cumulative Index to Nursing and Allied Health Literature, PubMed, ProQuest, Cochrane, Web of Science, PsycINFO, and Scopus databases using key words and MeSH terms was conducted. Screening identified studies employing qualitative and quantitative methods published between January 2000 and September 2019. Two reviewers independently appraised the methodological quality of the articles using the Mixed Methods Appraisal Tool (2018). Discussions were held among authors to examine quality scores of the studies and emergent themes, and agreement was reached through consensus. Themes were derived using inductive content analysis. Combined searches identified 1,065 citations. Of these, 19 articles, 16 quantitative and 3 qualitative, were included. Robotic-assisted surgeries included urology, gynecology, cardiac, and general procedures involving surgeons, anesthetists, nurses, and technicians. Three themes emerged: Negotiating the altered physical environs and adapting team communications to manage task and technology; managing the robotic system to optimize workflow efficiency; and technical proficiency depends on experience, team familiarity, and case complexity. Inclusion of a robot as a team member adds further complexity to the work of surgery. These review findings will inform training programs specifically designed to optimize teamwork, workflow efficiency, and learning needs.

The safety of computerised prescribing in hospitals.

SUMMARYThe implementation of computerised prescribing can result in large reductions in prescribing error rates. The flow-on effects to patient outcomes are not well studiedThe reduction in errors is dependent on prescribers becoming proficient in using the electronic prescribing system. All potential safety benefits are therefore not expected to be achieved immediatelyElectronic prescribing systems introduce new types of errors, most frequently errors in selection. Some of these errors can be prevented if the system is well designedComputerised decision support embedded in electronic prescribing systems has enormous potential to improve medication safety. However, current support systems have a limited capacity to provide context-relevant advice to prescribers

Design of hospital errors and omissions activities that include patient-specific medication related problems

Background and purposeMedication-related problems persist in hospital settings. New types of errors have emerged with changing technology. There is a need for updated, realistic, and patient-specific activities to train student pharmacists to identify medication-related problems. Educational activity and settingWe describe efforts to redesign hospital errors and omissions activities in a clinical skills lab course. A hospital errors and omissions template is described with multiple-choice answer options redesigned to reinforce that each instance of dispensing in a hospital is an opportunity for patient-centered care. FindingsIn the redesigned hospital errors and omissions activities, students identified the correct errors and omissions 77% of the time with an average point biserial of 0.491. Qualitative evaluation of student course evaluations and student self-selected learning goals suggest that students perceived the revised activity to be valuable. SummaryIt is possible to create and deliver hospital errors and omissions activities that include patient-specific medication related problems.

Errors and Complications in SQL Query Formulation

SQL is taught in almost all university level database courses, yet SQL has received relatively little attention in educational research. In this study, we present a database management system independent categorization of SQL query errors that students make in an introductory database course. We base the categorization on previous literature, present a class of logical errors that has not been studied in detail, and review and complement these findings by analyzing over 33,000 SQL queries submitted by students. Our analysis verifies error findings presented in previous literature and reveals new types of errors, namely logical errors recurring in similar manners among different students. We present a listing of fundamental SQL query concepts we have identified and based our exercises on, a categorization of different errors and complications, and an operational model for designing SQL exercises.

Quantum error-correcting code for ternary logic

Ternary quantum systems are being studied because these provide more computational state space per unit of information, known as qutrit. A qutrit has three basis states, thus a qubit may be considered as a special case of a qutrit where the coefficient of one of the basis states is zero. Hence both $(2 \times 2)$-dimensional as well as $(3 \times 3)$-dimensional Pauli errors can occur on qutrits. In this paper, we (i) explore the possible $(2 \times 2)$-dimensional as well as $(3 \times 3)$-dimensional Pauli errors in qutrits and show that any pairwise bit swap error can be expressed as a linear combination of shift errors and phase errors, (ii) propose a new type of error called quantum superposition error and show its equivalence to arbitrary rotation, (iii) formulate a nine qutrit code which can correct a single error in a qutrit, and (iv) provide its stabilizer and circuit realization.

Downtime in Digital Hospitals: An Analysis of Patterns and Causes Over 33 Months.

The use of health information technology (IT) is increasing around the world. However, as complex IT systems are implemented, new types of errors are introduced. These can disrupt workflow and care delivery, and even lead to patient harm. The purpose of this paper is to examine the patterns and causes of IT system downtime in a hospital setting. We examined all the downtime events that were recorded by a hospital IT department from February 2010 to October 2012. On average downtime disrupted care delivery for 49 hours per year with 51% of total downtime between 9 am and 5 pm. These results show that there is a need for safer design and implementation of IT systems. Further studies are required to measure the effects of downtime on care delivery and patient outcomes in digital hospitals.

A 2-D Space-Variant Motion Estimation and Compensation Method for Ultrahigh-Resolution Airborne Stepped-Frequency SAR With Long Integration Time

For the ultrahigh-resolution airborne stepped-frequency synthetic aperture radar, very large synthetic bandwidth and very long integration time may lead to a 2-D space-variant (SV) motion error when the aircraft flies off the ideally straight trajectory due to the atmospheric turbulence. This new type of error complicates the motion estimation and motion compensation (MOCO). For the motion estimation, we present a jointly 2-D SV motion error estimation method to simultaneously consider the range-variant motion error and the azimuth-variant motion error. For the MOCO, we propose a 2-D SV-MOCO method. The method is implemented through three processing steps: 1) two-step MOCO for the space-invariant motion error and the range-variant phase error; 2) range block-based chirp-z transform (CZT) for the range-variant envelope error; and 3) range block division for the range-dependent azimuth-variant phase error based on the azimuth subaperture method. Finally, processing of simulated data and real data validates the proposed methods.

Longitudinal study of user experiences of a CPOE system in a pediatric hospital

ObjectiveTo explore the views of nurses and doctors during the early stages of implementation of a computerized provider order entry (CPOE) system in a pediatric hospital and to examine changes in perceptions and reported behaviors as use of the CPOE system became routine. MethodsSemi-structured interviews were undertaken at four time points following CPOE implementation: during week one, week three, week six and then six months following implementation. In total, 122 users were interviewed. Interviews were audio-recorded and transcribed verbatim. Emergent themes were mapped to the Extended Technology Acceptance Model (e-TAM). ResultsInitial perceptions were driven by unfamiliarity with the system. As users became more proficient and efficient in using the CPOE system, additional safety benefits become apparent. However, accompanying increased reports of benefits were reports of usability problems and new types of errors arising from CPOE use. Reports of workarounds appeared for the first time at 6-month interviews. These workarounds were adopted to allow routine work to continue and to attenuate some of the perceived negative consequences of CPOE, including delayed medications and reduced patient interaction. ConclusionThis study is one of the first to examine changes in perceptions of CPOE at multiple points, demonstrating the trajectory of changes in views over time. It provides new information about the time point at which workarounds begin to be embedded in practice and are potentially most receptive to identification and remediation. It suggests an adaptive implementation and support program would be beneficial, as reported difficulties and concerns change during the first six months of use.

Estimation of surgical tool-tip tracking error distribution in coordinate reference frame involving pivot calibration uncertainty.

Accurate understanding of surgical tool-tip tracking error is important for decision making in image-guided surgery. In this Letter, the authors present a novel method to estimate/model surgical tool-tip tracking error in which they take pivot calibration uncertainty into consideration. First, a new type of error that is referred to as total target registration error (TTRE) is formally defined in a single-rigid registration. Target localisation error (TLE) in two spaces to be registered is considered in proposed TTRE formulation. With first-order approximation in fiducial localisation error (FLE) or TLE magnitude, TTRE statistics (mean, covariance matrix and root-mean-square (RMS)) are then derived. Second, surgical tool-tip tracking error in optical tracking system (OTS) frame is formulated using TTRE when pivot calibration uncertainty is considered. Finally, TTRE statistics of tool-tip in OTS frame are then propagated relative to a coordinate reference frame (CRF) rigid-body. Monte Carlo simulations are conducted to validate the proposed error model. The percentage passing statistical tests that there is no difference between simulated and theoretical mean and covariance matrix of tool-tip tracking error in CRF space is more than 90% in all test cases. The RMS percentage difference between simulated and theoretical tool-tip tracking error in CRF space is within 5% in all test cases.

Staff experience and perceptions of the safety and risks of electronic medication management systems in Victorian public hospitals

AbstractBackgroundVictorian hospitals are at various stages of transition to electronic medication management system (EMMS). Although improvements in medication safety and error reduction are assumed when using an EMMS, concerns have been raised regarding potential unintended consequences and possible new error types, so information from frontline staff using EMMSs provides an insight into their safety and some of the risks associated with their use.AimThe aims of this study were to determine the perceptions of frontline staff using an EMMS regarding the safety of the EMMS and the potential for new errors or those errors that were more likely with the use of an EMMS, and providing this feedback to the participating organisations.MethodFrontline clinical staff in eight Victorian hospitals using EMMS were invited to participate in voluntary, anonymous online survey designed and analysed by experienced medication safety pharmacists.ResultsRespondents (n = 664) included medical officers (30%) nurses (49%) and pharmacists (16%). Forty‐eight percent of respondents have observed, investigated or reviewed errors/near misses in EMMS. Fifty‐six percent believe that these errors/near misses are a new type of error related to EMMS. Top issues identified by those involved in an error (195) were incorrect patient selection and incorrect dose scheduling, resulting in dose duplication. Fifty‐six percent agree or strongly agree that EMMS has reduced the potential for medication errors and 58% consider that EMMS has introduced new types of errors. The most significant issues raised about EMMS were time‐consuming and non‐intuitive processes and overdependence on technology.ConclusionStaff experience and perception of EMMS was overall positive, most considering that medication error risk is reduced, but safety concerns remain to be addressed.