Rule-based Errors Research Articles

Understanding an epidemiological view of a retrospective audit of medication errors in an intensive care unit

BackgroundMedication errors in the intensive care setting continue to occur at significant rates and are often associated with adverse events and potentially life-threatening repercussions. Aim/objectiveThe aim of this study was to (i) determine the frequency and severity of medication errors reported in the incident management reporting system; (ii) examine the antecedent events, their nature, the circumstances, risk factors, and contributing factors leading to medication errors; and (iii) identify strategies to improve medication safety in the intensive care unit (ICU). MethodA retrospective, exploratory, descriptive design was selected. Retrospective data were collected from the incident report management system and electronic medical records over a 13-month period from a major metropolitan teaching hospital ICU. ResultsA total of 162 medication errors were reported during a 13-month period, of which, 150 were eligible for inclusion. Most medication errors occurred during the administration (89.4%) and dispensing phases (23.3%). The highest reported errors included incorrect doses (25.3%), incorrect medications (12.7%), omissions (10.7%), and documentation errors (9.3%). Narcotic analgesics (20%), anaesthetics (13.3%), and immunomodifiers (10.7%) were the most frequently reported medication classes associated with medication errors. Prevention strategies were found to be focussed on active errors (67.7%) as opposed to latent errors (32.3%) and included various and infrequent levels of education and follow-up. Active antecedent events included action-based errors (39%) and rule-based errors (29.5%), whereas latent antecedent events were most associated with a breakdown in system safety (39.3%) and education (25%). ConclusionThis study presents an epidemiological view and understanding of medication errors in an Australian ICU. This study highlighted the preventable nature of most medication errors in this study. Improving administration-checking procedures would prevent the occurrence of many medication errors. Approaches aimed at both individual- and organisational-level improvements are recommended to address administration errors and inconsistent medication-checking procedures. Areas for further research include determining the most effective system developments for improving administration-checking procedures and verifying the risk and prevalence of immunomodifier administration errors in the ICU as this is an area not reported previously in the literature. In addition, the impact of single- versus two-person checking procedures on medication errors in the ICU should be prioritised to address current evidence gaps.

Knowledge and perception of medication errors among health care workers in Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, North-west Nigeria.

Medication errors (MEs) are important, often overlooked forms of medical error that are associated with morbidity and mortality in health care settings. Among health care workers, knowledge, attitude and perception may affect reporting of MEs. The aim of this study was to determine the level of knowledge and perception of MEs among health care workers in Ahmadu Bello University Teaching Hospital, Zaria. A cross-sectional study was conducted among 138 health care workers selected randomly through a stratified sampling. Their responses were collected using pre-tested, self-administered questionnaires and analysed using the Statsitical Package for the Social Sciences. The numerical variables were summarised as means and standard deviations, whereas categorical variables were presented as frequencies and percentages. The Chi-square test was used to test for associations at P < 0.05. All the respondents heard of MEs and up to 108 (78.3%) correctly defined them. While only 121 (87.7%) respondents had fair to good knowledge about MEs, all of them had good perception of them. Major types of MEs known by the respondents were knowledge-based errors (79.7%), rule-based errors (52.9%), action-based errors (67.4%) and memory-based errors (55.8%). The causes of MEs identified were communication problems (88.4%), poor organizational knowledge transfer (63.8%), heavy workload (80.4%) and not reading instructions carefully (63.0%). There was no statistically significant association between the level of knowledge on MEs and sociodemographic characteristics of the respondents. Knowledge and perceptions of MEs were good among our respondents. Adequate mechanism (s) should be put in place to encourage the reporting of MEs whenever they occur to promote patient safety and improve health outcomes.

Spelling Error Analysis of Ghanaian Languages College of Education Students’ Essay

Spelling errors in students’ writing have become a burden for teachers and examiners of the Ghanaian languages. Every year, Chief Examiners of the Ghanaian languages lament bitterly in their reports about the inaccuracies students make with regard to spelling in their examinations without clearly indicating the kind of errors they make. As a result, this study investigated the frequency and types of spelling errors students of Ghanaian languages at the Foso College of Education make in their essays. Forty-five students took part in the study that utilized a descriptive qualitative approach. The data came from students’ mid-semester examinations. The findings revealed that students’ most prevalent spelling errors included sound-based substitution, writing rule-based, omission, addition, transposition, and multiple errors. Teachers are encouraged to give ample time or pay more attention to phonology and the writing rules of the language when teaching spelling because they were the most frequent errors found.

A structured method to achieve cognitive depth for medical device use error topic modeling

Human error associated with medical device use may lead to devastating consequences for end-users. Identifying post-market associations between instances of use error can inform human factors design decisions and guide regulatory action. The US Food and Drug Administration (FDA) requires medical device manufacturers, importers, and user facilities to track and report instances of adverse events. These reports are available in the Manufacturer and User Facility Experience (MAUDE) database. MAUDE exists to support post-market surveillance and to aid the discovery of adverse event-medical device associations. Each event contained in MAUDE contains an event narrative: a free-text description of the event. These event narratives are coded with a “device problem code” that describes the nature of each event that can aid in identifying trends, how,ever codes related to human factors are limited in detail. In the authors’ prior work, new use error categories for MAUDE entries were proposed tprovideides decomposition based on primary and secondary use error. In this work, these use error categories were used to structure entries based on narrative content. Topic modeling was performed for automatic extraction of narrative themes for use error MAUDE data from 2010 – 2019. Latent Dirichlet Allocation, an unsupervised generative model, was used to provide a descriptive analysis of this textual data and identify thematic topics. Notable outcomes included the categorization of narratives into six distinct topics; the first five primarily involved rule-based errors during the operation of glucose self-management devices, and the sixth involved knowledge-based errors during inpatient surgical procedures. Distinct divides between error narratives for healthcare providers and patients, as well as for different device types were observed, demonstrating an alignment with proposed use error categories. These categories can be used to monitor trends for specific medical device user segments and can inform device manufacturers of usability design requirements that must be addressed.

Innovating teacher feedback with writing activities aimed at raising secondary school students’ awareness of collocation errors

The study examined the types of written corrective feedback given by second language writing teachers on Taiwanese secondary school students’ collocation errors. First, the written corrective feedback that teachers provided on learners’ word choice errors was examined to uncover the types of feedback provided. Then, analysis focused on verb–noun collocations to draw attention to how students had been receiving different types of written corrective feedback from teachers on a single collocation error type. Results showed that some sentences tagged as including word choice errors only contained rule-based errors. Furthermore, for verb-noun collocation errors, teachers chose to provide indirect and direct feedback almost equally at the expense of metalinguistic feedback. Based on the results, we suggested options for second language writing teachers when providing feedback on word choice errors.

Patient safety in radiology: Our experience

BackgroundPresent-day radiology departments have very high footfall of patients and are prone to patient safety errors. This study analyses such errors in our hospital. MethodsObservational cross-sectional analysis of errors over the last 30 months was performed. These were classified using the Eindhoven classification model into technical, organizational, and human errors. Technical errors focused on equipment safety. Organizational errors related to policies. Human errors were subclassified as per the skill rule knowledge model. Root cause analysis was performed wherever necessary, and possible mitigation strategies for ensuring safety were suggested. Errors peculiar to the Armed Forces environment were specifically addressed. ResultsSeventy-seven errors were analyzed. Two were equipment based including faulty pressure injector syringes and radiation leakage from the computed tomography gantry. Of 44 skill-based errors, 09 involved dispatch of wrong reports to dependents owing to identifying patients with serving personnel's name. Four were due to scanning wrong sites. Eleven involved reporting abnormality on the wrong side. Six involved underreporting due to not viewing specific images. The rest were due to failure to omit conflicting elements in the report. Rule-based errors included wrong protocol selection (9 errors), omitting a particular sequence due to individual preference (6 errors), and so on. Knowledge-based errors were due to misinterpretation of findings (4 errors), reporting an abnormality as normal (3 errors), and selection of wrong modality (3 errors). ConclusionThe findings of this study highlights the importance of voluntary reporting, diligent recording, and in-depth analysis of errors for understanding the causes and formulating possible mitigation strategies.

Impression formation on online dating sites: Effects of language errors in profile texts on perceptions of profile owners’ attractiveness

This article presents two experimental studies investigating the impact of language errors in online dating profiles on impression formation. A first study examined whether language errors have a negative effect on perceptions of attraction and dating intention and whether this effect is moderated by the presence of visual information, that is, the profile picture. This 2 (Language Errors/No Language Errors) × 2 (Visible/Blurred Picture) experiment revealed that language errors negatively affect perceptions of social and romantic attraction and that a visible picture on a profile positively affects perceptions of physical attraction. Study 2 focused on mechanical, rule-based, and informal language errors, which can each be attributed to different personality traits. Mechanical and rule-based errors lead to lower scores on, respectively, perceived attentiveness and intelligence, which in turn lead to lower attraction and dating intention scores. These results highlight the importance of error-free language use as a cue for attractiveness.

Abu Dhabi Police Ambulance EMTs Medical Errors January-October 2018

Introduction:Medical errors are a reality for Emergency Medical Technicians (EMT’s) working in a prehospital, high-stress environment. A “medical error” can be defined as a mistake or system failure which results in improper care of a patient’s injury.Aim:To study the frequency, severity, types, and causes of medical errors committed by Abu Dhabi Police Ambulance (ADPA) crews, and how to prevent these errors. The study is retrospective. All the data was collected using the Electronic Patient Care Report (EPCR) of all the patient treated and transported by ADPA crew from January to October 2018. After the EPCR auditing and monitoring, the medical errors were identified and discussed by a medical committee.Results:The total number of studied EPCR (trauma and medical cases) was 36.000. The medical errors identified were 265 cases (0.74%). 134 cases (51%) were moderate (can cause side effects), 115 cases (43%) were minor, and 16 cases (6%) were critical (can lead to death). The most common type of medical errors were cognitive errors. The causes were skill-based errors 27 times (10%) with 16 intravenous failures, 10 intraosseous failures, and one dislodged endotracheal tube after orotracheal intubation. The rule-based errors were committed five times (2%) when the Paramedics did not follow ACLS Algorithm, three times shockable cardiac arrest and two times Pulseless Electrical Activity. The knowledge-based errors were drug indications errors five times (2%). The three EMT’s levels in ADPA (Basic, Intermediate, and advanced) committed medical errors. The question to ask is not who made the mistake, but why the mistake was made. Preventing ADPA crew errors requires a systematic approach to modify the conditions that contribute to errors. The strategies are developing more awareness of cognitive errors by education and incorporating simulation into training.

Learning from errors in insurance companies

PurposeThe study pursues two goals: first, as a replication study, the purpose of this paper is to test a model of learning from errors in the domain of insurance industry. Second, to increase insights in learning from errors, the authors focussed on different types of errors.Design/methodology/approachThe authors conducted a cross-sectional survey in the insurance industry (N=206). The authors used structural equation modelling and path modelling to analyse the data. To be able to analyse different types of errors, the authors used Critical Incident Technique and asked participants to describe error situations.FindingsFindings from the study are that the model of learning from errors could partly be replicated. The results indicate that a non-punitive orientation towards errors is an important factor to reduce the tendency of insurance agents to cover up errors when knowledge and rule-based errors happen. In situations of slips and lapses error strain has a negative influence on trust and non-punitive orientation which in turn both reduce the tendency to cover up errors.Research limitations/implicationsLimitation is the small sample size. By using Critical Incidents Technique, the authors were able to analyse authentic error situations. Implications of the results concern the importance of error-friendly climate in organisations.Originality/valueReplication studies are important to generalise results to different domains. To increase the insight in learning from errors, the authors analysed influencing factors with regard to different types of errors.

Residents' surgical performance during the laboratory years: an analysis of rule-based errors

BackgroundNearly one-third of surgical residents will enter into academic development during their surgical residency by dedicating time to a research fellowship for 1-3 y. Major interest lies in understanding how laboratory residents' surgical skills are affected by minimal clinical exposure during academic development. A widely held concern is that the time away from clinical exposure results in surgical skills decay. This study examines the impact of the academic development years on residents' operative performance. We hypothesize that the use of repeated, annual assessments may result in learning even without individual feedback on participants simulated performance. MethodsSurgical performance data were collected from laboratory residents (postgraduate years 2-5) during the summers of 2014, 2015, and 2016. Residents had 15 min to complete a shortened, simulated laparoscopic ventral hernia repair procedure. Final hernia repair skins from all participants were scored using a previously validated checklist. An analysis of variance test compared the mean performance scores of repeat participants to those of first time participants. ResultsTwenty-seven (37% female) laboratory residents provided 2-year assessment data over the 3-year span of the study. Second time performance revealed improvement from a mean score of 14 (standard error = 1.0) in the first year to 17.2 (SD = 0.9) in the second year, (F[1, 52] = 5.6, P = 0.022). Detailed analysis demonstrated improvement in performance for 3 grading criteria that were considered to be rule-based errors. There was no improvement in operative strategy errors. ConclusionsAnalysis of longitudinal performance of laboratory residents shows higher scores for repeat participants in the category of rule-based errors. These findings suggest that laboratory residents can learn from rule-based mistakes when provided with annual performance-based assessments. This benefit was not seen with operative strategy errors and has important implications for using assessments not only for performance analysis but also as a learning experience.

Automatic Chinese Factual Question Generation

Question generation is an emerging research area of artificial intelligence in education. Question authoring tools are important in educational technologies, e.g., intelligent tutoring systems, as well as in dialogue systems. Approaches to generate factual questions, i.e., questions that have concrete answers, mainly make use of the syntactical and semantic information in a declarative sentence, which is then transformed into questions. Recently, some research has been conducted to investigate Chinese factual question generation with some limited success. Reported performance is poor due to unavoidable errors (e.g., sentence parsing, name entity recognition, and rule-based question transformation errors) and the complexity of long Chinese sentences. This article introduces a novel Chinese question generation system based on three stages, sentence simplification, question generation and ranking, to address the challenge of automatically generating factual questions in Chinese. The proposed approach and system have been evaluated on sentences from the New Practical Chinese Reader corpus . Experimental results show that ranking improves more than 20 percentage of questions rated as acceptable by annotators, from 65 percent of all questions to 87 percent of the top ranked 25 percent questions.

The use of a contextual, modal and psychological classification of medication errors in the emergency department: a retrospective descriptive study.

To describe the contextual, modal and psychological classification of medication errors in the emergency department to know the factors associated with the reported medication errors. The causes of medication errors are unique in every clinical setting; hence, error minimisation strategies are not always effective. For this reason, it is fundamental to understand the causes specific to the emergency department so that targeted strategies can be implemented. Retrospective analysis of reported medication errors in the emergency department. All voluntarily staff-reported medication-related incidents from 2010-2015 from the hospital's electronic incident management system were retrieved for analysis. Contextual classification involved the time, place and the type of medications involved. Modal classification pertained to the stage and issue (e.g. wrong medication, wrong patient). Psychological classification categorised the errors in planning (knowledge-based and rule-based errors) and skill (slips and lapses). There were 405 errors reported. Most errors occurred in the acute care area, short-stay unit and resuscitation area, during the busiest shifts (0800-1559, 1600-2259). Half of the errors involved high-alert medications. Many of the errors occurred during administration (62·7%), prescribing (28·6%) and commonly during both stages (18·5%). Wrong dose, wrong medication and omission were the issues that dominated. Knowledge-based errors characterised the errors that occurred in prescribing and administration. The highest proportion of slips (79·5%) and lapses (76·1%) occurred during medication administration. It is likely that some of the errors occurred due to the lack of adherence to safety protocols. Technology such as computerised prescribing, barcode medication administration and reminder systems could potentially decrease the medication errors in the emergency department. There was a possibility that some of the errors could be prevented if safety protocols were adhered to, which highlights the need to also address clinicians' attitudes towards safety. Technology can be implemented to help minimise errors in the ED, but this must be coupled with efforts to enhance the culture of safety.

Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital

This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.

Use of a human factors classification framework to identify causal factors for medication and medical device-related adverse clinical incidents

This study examined non-fatal adverse clinical incidents involving patient loss of function or requiring increased levels of care of a patient relating to medication and medical devices to determine if incident causal factors can be identified using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 200 medication- and 200 medical device-related clinical incidents in Australia were reviewed using the HFCF for patient safety. The framework identified key precursor events (PE) and contributing factors (CF) of these events. Descriptive statistics and correspondence analysis were used to examine the characteristics of the events. Medication and communication or documentation issues were the most common types of PE identified for medication incidents, while for medical devices the most common PEs were medical device breakage/failure or lack of medical equipment. Correspondence analysis for medication incidents showed that rule-based errors were strongly related to omitted dose or wrong drug. Factors relating to the organisation (86.5% and 25.0%) or the patient (7.7% and 17.9%) were the most commonly identified CFs for both medication and medical device-related incidents, respectively. The HFCF for patient safety identified the role of human factors, particularly human error, in non-fatal clinical incidents involving medication and medical devices, highlighting the need for targeted approaches to inform risk management strategies in the healthcare sector based on an understanding of how and why these incidents occur.

Sentencing Rules and Standards: How We Decide Criminal Punishment

Over the course of the past 300 years, American sentencing policy has alternated between “determinate” and “indeterminate” systems of deciding punishment. Debates over sentence determinacy have so far focused on three main questions: Who should decide punishment? What makes punishment fair? And why should we punish wrongdoers at all? In this Article, I ask a new, fourth, question: How should we decide punishment? I show that determinate sentencing uses rules to determine sentences, while indeterminate sentencing relies on standards. Applying this insight to federal sentencing practice, I demonstrate that district court judges “depart” or “vary” from the United States Sentencing Guidelines in order to correct the substantive and formal errors that result from rule-based decisionmaking, instead sentencing in such cases based on the § 3553(a) standard. I argue that judges should be more willing to take departures and variances in cases involving particularly large or particularly numerous sentence adjustments, which exacerbate the impact of rule-based errors.

GRP-131 Patient Safety – Analysing Medication-Related Adverse Events

BackgroundMedication-related adverse events (AEs) lead to increased morbidity, mortality and costs. In Denmark, frontline personnel in hospitals and in the primary care sector are obligated to report adverse events to...

A CIRCADIAN RHYTHM IN SKILL-BASED ERRORS IN AVIATION MAINTENANCE

In workplaces where activity continues around the clock, human error has been observed to exhibit a circadian rhythm, with a characteristic peak in the early hours of the morning. Errors are commonly distinguished by the nature of the underlying cognitive failure, particularly the level of intentionality involved in the erroneous action. The Skill-Rule-Knowledge (SRK) framework of Rasmussen is used widely in the study of industrial errors and accidents. The SRK framework describes three fundamental types of error, according to whether behavior is under the control of practiced sensori-motor skill routines with minimal conscious awareness; is guided by implicit or explicit rules or expertise; or where the planning of actions requires the conscious application of domain knowledge. Up to now, examinations of circadian patterns of industrial errors have not distinguished between different types of error. Consequently, it is not clear whether all types of error exhibit the same circadian rhythm. A survey was distributed to aircraft maintenance personnel in Australia. Personnel were invited to anonymously report a safety incident and were prompted to describe, in detail, the human involvement (if any) that contributed to it. A total of 402 airline maintenance personnel reported an incident, providing 369 descriptions of human error in which the time of the incident was reported and sufficient detail was available to analyze the error. Errors were categorized using a modified version of the SRK framework, in which errors are categorized as skill-based, rule-based, or knowledge-based, or as procedure violations. An independent check confirmed that the SRK framework had been applied with sufficient consistency and reliability. Skill-based errors were the most common form of error, followed by procedure violations, rule-based errors, and knowledge-based errors. The frequency of errors was adjusted for the estimated proportion of workers present at work/each hour of the day, and the 24 h pattern of each error type was examined. Skill-based errors exhibited a significant circadian rhythm, being most prevalent in the early hours of the morning. Variation in the frequency of rule-based errors, knowledge-based errors, and procedure violations over the 24 h did not reach statistical significance. The results suggest that during the early hours of the morning, maintenance technicians are at heightened risk of “absent minded” errors involving failures to execute action plans as intended. (Author correspondence: alan.hobbs@nasa.gov)

Workplace errors and negative knowledge in elder care nursing

Expert professionals excel in their domains not only because of their superior knowledge about how to proceed to attain goals, but also because of their experiential knowledge about what may endanger the attainment of a goal and should therefore be avoided. This negative knowledge is researched here by means of a case study with practitioners in elder care nursing. It explores (1) what forms of workplace errors negative knowledge is related to, and (2) draws conclusions on error-producing conditions at the participants' workplaces. The results indicate that negative knowledge mainly, but not exclusively, relates to knowledge- and rule-based errors. Moreover, it provides insights into underlying tensions at the elder care nurses' workplaces, such as the requirement to make the residents follow medical suggestions, while also respecting their biography and autonomy. With regard to its potential for better understanding the competence of professionals to avoid errors, it is concluded that the concept of negative knowledge should more purposefully be developed at the individual and the organizational level.

Effects of peer- versus self-editing on students’ revision of language errors in revised drafts

Abstract Previous research on the effects of peer-editing in bringing about language development generally examined the linguistic performance of only a few students and did not focus on specific language errors nor used a control group. To counteract these limitations, this study used a pre-test/post-test comparison group quasi-experimental design to compare the effects of peer-editing to that of self-editing on students’ correction of specific language errors in revised drafts. The language errors under study are two rule-based errors (subject/verb agreement, pronoun agreement) and two non rule-based errors (wrong word choice, awkward sentence structure). Results revealed that compared to the comparison group, the experimental group significantly reduced their rule-based errors in revised drafts but not the non rule-based errors. Since both groups received teacher instruction in editing language errors, but only the experimental group engaged in peer-editing, these results may be attributed to peer-editing. The study contributes to teaching pedagogy by encouraging teachers to use peer-editing in the writing classroom and to focus on the correction of few language errors to bring about language development.

Feasibility and reliability of PRISMA-Medical for specialty-based incident analysis

Aims and objectives:In this study, the feasibility and reliability of the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method for systematic, specialty-based analysis and classification of incidents in...