Unreported Errors Research Articles

Automated detection of vertebral body misalignments in orthogonal kV and MV guided radiotherapy: application to a comprehensive retrospective dataset

Objective. In image-guided radiotherapy (IGRT), off-by-one vertebral body misalignments are rare but potentially catastrophic. In this study, a novel detection method for such misalignments in IGRT was investigated using densely-connected convolutional networks (DenseNets) for applications towards real-time error prevention and retrospective error auditing. Approach. A total of 4213 images acquired from 527 radiotherapy patients aligned with planar kV or MV radiographs were used to develop and test error-detection software modules. Digitally reconstructed radiographs (DRRs) and setup images were retrieved and co-registered according to the clinically applied alignment contained in the DICOM REG files. A semi-automated algorithm was developed to simulate patient positioning errors on the anterior-posterior (AP) and lateral (LAT) images shifted by one vertebral body. A DenseNet architecture was designed to classify either AP images individually or AP and LAT image pairs. Receiver-operator characteristic curves (ROC) and areas under the curves (AUC) were computed to evaluate the classifiers on test subsets. Subsequently, the algorithm was applied to the entire dataset in order to retrospectively determine the absolute off-by-one vertebral body error rate for planar radiograph guided RT at our institution from 2011–2021. Main results. The AUCs for the kV models were 0.98 for unpaired AP and 0.99 for paired AP-LAT. The AUC for the MV AP model was 0.92. For a specificity of 95%, the paired kV model achieved a sensitivity of 99%. Application of the model to the entire dataset yielded a per-fraction off-by-one vertebral body error rate of 0.044% [0.0022%, 0.21%] for paired kV IGRT including one previously unreported error. Significance. Our error detection algorithm was successful in classifying vertebral body positioning errors with sufficient accuracy for retrospective quality control and real-time error prevention. The reported positioning error rate for planar radiograph IGRT is unique in being determined independently of an error reporting system.

It's the little THANGS: Recording frequently unreported errors for dosimetry quality improvement

The reporting of errors resulting in dose deviations are well-studied. Less studied is the amount of inconsequential errors that will not harm the patient but could lead to inefficiency. This paper reports an institutional effort to quantify and reduce these less significant errors. Dosimetry items discovered during physicist plan/record and verify (R&V) check prior to treatment were recorded in a shared document and called Therapy Anomaly Gathering System (THANGS) and individual items were called a “thang.” Items were categorized to 1 of 4 types: Treatment Plan, Plan Document, R&V, and Secondary MU. The aggregate numbers were presented to the dosimetry staff at regular staff meetings. It was emphasized to the staff that this was a Quality Improvement (QI) study and would not be used punitively. Thangs were tracked over a 4-year period. In Q1 of year 1 of the study, the average number of errors identified was 179/month. This was reduced to 114/month by Q4 of year 1 and 68/month by the end of year 4, a 62% reduction. The number of errors/plan in Q1 Year 1 was 1.25, and that was reduced by Q4 Year 4 to 0.4, a 68% reduction. The percentage of errors by type did not vary much over the 4 years. By far, R&V errors were the most common, and QI efforts were primarily aimed at them. We have developed a simple method to identify areas in dosimetric work that are vulnerable to minor errors and, through consistent reminders, drastically reduce them. This leads to a seamless throughput for a given plan ultimately resulting in improved physics, therapist, and most importantly patient satisfaction.

A little doubt saves many mistakes: Early and late error detection in copy-typing

Abstract Based on internal predictions, action-errors can be detected relatively early. Different kinds of sensory feedback further provide information about the occurrence of errors later on. To investigate the mechanisms underlying error detection in copy-typing, ten-finger-typists and hunt-and-peck-typists copy typed with and without visibility of the screen and keyboard. We expected that error detection evolves in slower typing before, during, and after an error. Results showed that more errors were reported with visible screen than with covered screen in both groups underpinning the importance of distal action-effects for error detection. Importantly, ten-finger-typists showed pre-error-slowing in the inter-keystroke-intervals (IKIs) before reported errors, but hunt-and-peck-typists did not. In both groups, error-slowing was observed in the last IKI before both reported and unreported errors. Hence, internal predictions play a role in error detection in both groups, but in ten-finger-typists, internal models may be more precise, leading to earlier error detection. Alternatively, slowing down may increase the probability of detecting errors. Finally, in both groups post-error-slowing indicates that sensory feedback from performing keystrokes contributes to error detection. In conclusion, feedback from distal action-effects (i.e., the screen), movement related feedback, and predictive mechanisms contribute to error detection in typing.

The effects of using intraoperative care documentation forms on the number of reported errors

Background: Reporting intraoperative errors can help reduce the incidence of more errors. However, some errors remain unreported. A key strategy to improve error reporting is quality care documentation. Objectives: The aim of this study was to determine the effects of using intraoperative care documentation forms on the number of reported errors. Methods: This single-group pretest–posttest interventional study was conducted on 65 operating room technicians and nurses recruited from the operating rooms of Alzahra and Kashani Teaching Hospitals, Isfahan, Iran. A researcher-made error-reporting questionnaire was used to assess the rate of reported and unreported errors both 1 week before and 2 months after the study intervention. During the study intervention, participants were asked to perform intraoperative care documentation for 2 successive months using five researcher-made intraoperative care documentation forms. Data were analyzed through the McNemar's and Wilcoxon tests and the Spearman's correlation analysis. Results: The mean score of intraoperative care documentation had a direct correlation with the number of written-reported errors (P = 0.044) and an inverse correlation with the number of unreported errors (P = 0.047). The number of written-reported errors significantly increased (P = 0.009), whereas the number of unreported errors significantly decreased after the study intervention (P = 0.017). Conclusion: Intraoperative care documentation can significantly increase the rate of error reporting. Therefore, the intraoperative care documentation forms developed in this study can be used to improve operating room staff's documentation and error-reporting practice.

A blunted phasic autonomic response to errors indexes age-related deficits in error awareness.

Conscious error detection is impaired in older age, yet it is unclear which age-related changes in the nervous system contribute to this deficit. In younger adults, error commission is accompanied by phasic autonomic arousal, which purportedly contributes to conscious error detection. Because aging is associated with declining autonomic reactivity, reduced phasic arousal to errors may therefore contribute to age-related error detection deficits. To test this, we measured pupil dilation in younger (<30years) and older (60-80years) healthy adults during an eye movement task. The task required a subjective assessment of response accuracy, as well as a "meta-judgment" of the certainty underlying that accuracy-assessment. This allowed for a precise quantification of subjective error awareness. Behaviorally, we found reduced error awareness in older adults. Furthermore, while younger adults showed "residual" awareness of error commission on unreported errors (indicated by decreased rating certainty compared with correct responses), this effect was absent in older adults. Notably, pupil dilation correlated with both measures: between subjects, greater pupil dilation to reported errors was correlated with greater subjective certainty of error detection, and greater pupil dilation to unreported errors was correlated with greater "residual" awareness of unreported errors. In line with this association, older adults showed a reduced pupil response to both reported and unreported errors. Notably, older adults showed no pupil dilation to unreported errors, in line with their lack of "residual" error awareness on such trials. Taken together, our results suggest that reduced autonomic reactivity may contribute to age-related error awareness deficits.

Prevalence and reporting of recruitment, randomisation and treatment errors in clinical trials: A systematic review.

Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation or treatment errors was found in the remaining 50 of 82 trials (61%). Based on responses from 9 of the 15 corresponding authors who were contacted regarding recruitment, randomisation and treatment errors, between 1% and 100% of the errors that occurred in their trials were reported in the trial publications. Conclusion Recruitment, randomisation and treatment errors are common in individually randomised, phase III trials published in leading medical journals, but reporting practices are inadequate and reporting standards are needed. We recommend researchers report all such errors that occurred during the trial and describe how they were handled in trial publications to improve transparency in reporting of clinical trials.

Simulating and quantifying legacy topographic data uncertainty: an initial step to advancing topographic change analyses

Rapid technological advances, sustained funding, and a greater recognition of the value of topographic data have helped develop an increasing archive of topographic data sources. Advances in basic and applied research related to Earth surface changes require researchers to integrate recent high-resolution topography (HRT) data with the legacy datasets. Several technical challenges and data uncertainty issues persist to date when integrating legacy datasets with more recent HRT data. The disparate data sources required to extend the topographic record back in time are often stored in formats that are not readily compatible with more recent HRT data. Legacy data may also contain unknown error or unreported error that make accounting for data uncertainty difficult. There are also cases of known deficiencies in legacy datasets, which can significantly bias results. Finally, scientists are faced with the daunting challenge of definitively deriving the extent to which a landform or landscape has or will continue to change in response natural and/or anthropogenic processes. Here, we examine the question: how do we evaluate and portray data uncertainty from the varied topographic legacy sources and combine this uncertainty with current spatial data collection techniques to detect meaningful topographic changes? We view topographic uncertainty as a stochastic process that takes into consideration spatial and temporal variations from a numerical simulation and physical modeling experiment. The numerical simulation incorporates numerous topographic data sources typically found across a range of legacy data to present high-resolution data, while the physical model focuses on more recent HRT data acquisition techniques. Elevation uncertainties observed from anchor points in the digital terrain models are modeled using “states” in a stochastic estimator. Stochastic estimators trace the temporal evolution of the uncertainties and are natively capable of incorporating sensor measurements observed at various times in history. The geometric relationship between the anchor point and the sensor measurement can be approximated via spatial correlation even when a sensor does not directly observe an anchor point. Findings from a numerical simulation indicate the estimated error coincides with the actual error using certain sensors (Kinematic GNSS, ALS, TLS, and SfM-MVS). Data from 2D imagery and static GNSS did not perform as well at the time the sensor is integrated into estimator largely as a result of the low density of data added from these sources. The estimator provides a history of DEM estimation as well as the uncertainties and cross correlations observed on anchor points. Our work provides preliminary evidence that our approach is valid for integrating legacy data with HRT and warrants further exploration and field validation.

Detailed analysis of error patterns in the number-transcoding task on the Japanese version of the Rapid Dementia Screening Test.

The number-transcoding task on the Japanese version of the Rapid Dementia Screening Test requires mutual conversion between Arabic and Chinese numerals (e.g. 209 → , 4054 → , → 681, → 2027). During this task, some characteristic errors have been seen among patients with Alzheimer's disease (AD). The objective of this study was to clarify whether the frequency of appearance of error patterns differs between patients with mild and severe AD according to Clinical Dementia Rating (CDR) scores. A total of 250 patients with AD were recruited and subsequently categorized into two groups based on CDR scores (mild AD: CDR of 0.5 or 1; severe AD: CDR of 2 or 3). We analyzed 19 qualitative error patterns, including 15 that had been reported to date and 4 previously unreported errors, in each subtest. The frequency of appearance of two previously reported and four previously unreported errors in the mild and severe AD groups, respectively, were statistically significant. Characteristic error pattern distributions in number transcoding can be observed in patients with mild and severe AD according to CDR scores and offers useful information for interpreting cognitive screening data.

Removing low-frequency artefacts from Datawell DWR-G4 wave buoy measurements

Abstract. In this study we describe a previously unreported error in the vertical-displacement time series made with GPS-based Datawell DWR-G4 wave buoys and introduce a simple method to correct the resulting wave spectra. The artefact in the time series is found to resemble a sawtooth wave, which produces an erroneous trend following an f−2 power law in frequency space. The correction method quantifies the amount of erroneous trend below a certain maximum frequency and removes the spurious energy from all frequencies assuming the above-mentioned f−2 power law. The presented correction method is validated against an experimental field test, and its impact on the measured significant wave height is quantified. The method's sensitivity to the choice of the maximum frequency is also briefly discussed.

The Mediation Effect of Organizational Climate on the Relationship between HPWS and Perception of Patient Safety

The main aim of this paper is to investigate the mediation effect of organizational climate on the relationship between HPWS and perception of patient safety in Saudi Hospitals. Patient safety has become a significant topic among health professionals, policy makers, and the public owing to the emphasis on the reported and unreported healthcare errors that result in negative situations. A quantitative research design was adopted to collect data. Out of 254 questionnaires returned which are content to 202 questionnaires returned from 112 general hospitals and 52 from 33 specialist hospitals only 217 questionnaires used for analysis. The Partial Least Squares Structural Equation Modeling (PLS-SEM) method was used to conduct this study. The findings of the study will contribute to both theory and practice. The results of this study have important contributions and implications for practitioners and policy-makers. This study contributed to the field of organizational climate on patient safety in Saudi Hospitals. It is contended that organizational climate was found to play a pivotal role in the model, as it had a direct significant impact on patient safety and frequency of occurrence of adverse events, and had a partial mediating effect on the relationship between HPWS and patient safety.

Correcting the SIMPLE model of free recall.

The scale-invariant memory, perception, and learning (SIMPLE) model developed by Brown, Neath, and Chater (2007) formalizes the theoretical idea that scale invariance is an important organizing principle across numerous cognitive domains and has made an influential contribution to the literature dealing with modeling human memory. In the context of free recall data, however, there is a previously unreported conceptual error in the specification of the SIMPLE model. We show that the error matters not only in theory but also in practice by reapplying the corrected SIMPLE model to the benchmark data reported by Murdock (1962). The corrected model makes different predictions about serial position curves, shows better fit to the Murdock (1962) data, and infers different parameters that require substantively different psychological interpretation.

항공정비 분야의 공정한 안전문화 개선방안에 관한 연구

Aviation Maintenance Technician(AMT)'s error is not directly link to deficiency which is differ to flight crew's error and it potentially maintains. Due to it usually occur as undesired aircraft state, hazards, like unreported maintenance error or near miss fortunately undetected and are not develop to accident. This could be a crucial influence of an accident occurrence. To remove these hazards, just safety culture should be support that anyone can report about safety problems and person who reported safety problems and hazards like near miss, should not get disadvantages. Also if it is satisfied, they must exempt for punishment and guaranteed for security. Hence, on this study, aviation maintenance site's just culture need to be researched and analysed about improvement for aviation maintenance field's positive just culture.

Corrections

Corrections| April 01 2008 Corrections Crit Care Nurse (2008) 28 (2): 19. https://doi.org/10.4037/ccn2008.28.2.19 Connected Content Errata: Critical Care Nurse: Unreported Errors in the Intensive Care Unit: A Case Study of the Way We Work Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Cite Icon Cite Get Permissions Citation Corrections. Crit Care Nurse 1 April 2008; 28 (2): 19. doi: https://doi.org/10.4037/ccn2008.28.2.19 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentCritical Care Nurse Search Advanced Search The CE test following the article Unreported Errors in the Intensive Care Unit: A Case Study of the Way We Work (October 2007;27:27–35) should list Category: O, Synergy CERP C instead of Category: A, Synergy CERP A. The correct URL in the reference following the letter to the editor regarding Enteral Feedings and a Common Problem in the February issue (February 2008;28:14) is http://www.criticalcarenutrition.com/docs/tools/Diarrhea%20Algorithm.pdf. View Original Article You do not currently have access to this content.

Honest, accurate, and magnificent article

“Brilliant” is the only word to describe Elizabeth Henneman’s article in the October issue of Critical Care Nurse entitled “Unreported Errors in the Intensive Care Unit” (October 2007:27–34). And the brilliance showed in so many ways. From identifying the 8 errors that occurred with her own patients during a single shift, to delineating the types of errors involved and her insightful discussion of how we all fail to recognize chronic systems problems as contributors to error, Henneman has broken new ground in the conversation about safety in nursing and healthcare. This article is a valuable contribution to the growing body of literature on safety and harm—and certainly it is the most unique and practical one that I have read.Besides the attributes of the article already mentioned, by far the most powerful feature is the author’s willingness to share her introspection and flaws in her own practice with thousands of readers as she so honestly analyzes the events in the course of her 12-hour shift. This important work should be required reading for everyone on the front line of healthcare today for its honesty, its accuracy, and its magnificent contribution to our thinking. I will work to make it so in my institution. Kudos, Elizabeth!

Unreported Errors in the Intensive Care Unit

Unreported Errors in the Intensive Care Unit

Searching for the final answer: factors contributing to medication administration errors.

Medication errors have reached epidemic proportions in the United States with proposed resolutions having little effect. Many errors go unreported because of nurses' fear of retaliation. Yet these unreported errors may contain the very information needed to uncover system flaws. Until all causes are examined and researched thoroughly, systems will continue to fail. These unknown factors contributing to medication errors will remain elusive unless health care providers are willing and able to focus attention where it is needed-on systems rather than individuals. Patients have enough fears when entering health care institutions; medication errors should not be one of them.

The impact of treatment complexity and computer-control delivery technology on treatment delivery errors

Purpose: To analyze treatment delivery errors for three-dimensional (3D) conformal therapy performed at various levels of treatment delivery automation and complexity, ranging from manual field setup to virtually complete computer-controlled treatment delivery using a computer-controlled conformal radiotherapy system (CCRS). Methods and Materials: All treatment delivery errors which occurred in our department during a 15-month period were analyzed. Approximately 34,000 treatment sessions (114,000 individual treatment segments [ports]) on four treatment machines were studied. All treatment delivery errors logged by treatment therapists or quality assurance reviews (152 in all) were analyzed. Machines “M1” and “M2” were operated in a standard manual setup mode, with no record and verify system (R/V). MLC machines “M3” and “M4” treated patients under the control of the CCRS system, which (1) downloads the treatment delivery plan from the planning system; (2) performs some (or all) of the machine set up and treatment delivery for each field; (3) monitors treatment delivery; (4) records all treatment parameters; and (5) notes exceptions to the electronically-prescribed plan. Complete external computer control is not available on M3; threfore, it uses as many CCRS features as possible, while M4 operates completely under CCRS control and performs semi-automated and automated multi-segment intensity modulated treatments. Analysis of treatment complexity was based on numbers of fields, individual segments, nonaxial and noncoplanar plans, multisegment intensity modulation, and pseudoisocentric treatments studied for a 6-month period (505 patients) concurrent with the period in which the delivery errors were obtained. Treatment delivery time was obtained from the computerized scheduling system (for manual treatments) or from CCRS system logs. Treatment therapists rotate among the machines; therefore, this analysis does not depend on fixed therapist staff on particular machines. Results: The overall reported error rate (all treatments, machines) was 0.13% per segment, or 0.44% per treatment session. The rate (per machine) depended on automation and plan complexity. The error rates per segment for machines M1 through M4 were 0.16%, 0.27%, 0.12%, 0.05%, respectively, while plan complexity increased from M1 up to machine M4. Machine M4 (the most complex plans and automation) had the lowest error rate. The error rate decreased with increasing automation in spite of increasing plan complexity, while for the manual machines, the error rate increased with complexity. Note that the real error rates on the two manual machines are likely to be higher than shown here (due to unnoticed and/or unreported errors), while (particularly on M4) virtually all random treatment delivery errors were noted by the CCRS system and related QA checks (including routine checks of machine and table readouts for each treatment). Treatment delivery times averaged from 14 min to 23 min per plan, and depended on the number of segments/plan, although this analysis is complicated by other factors. Conclusion: Use of a sophisticated computer-controlled delivery system for routine patient treatments with complex 3D conformal plans has led to a decrease in treatment delivery errors, while at the same time allowing delivery of increasingly complex and sophisticated conformal plans with little increase in treatment time. With renewed vigilance for the possibility of systematic problems, it is clear that use of complete and integrated computer-controlled delivery systems can provide improvements in treatment delivery, since more complex plans can be delivered with fewer errors, and without increasing treatment time.

Low-cost, Concurrent Checking of Pointer and Array Accesses in C Programs

Illegal pointer and array accesses are a major cause of failure for C programs. We present a technique called ‘guarding’ to catch illegal array and pointer accesses. Our implementation of guarding for C programs works as a source-to-source translator. Auxiliary objects called guards are added to a user program to monitor pointer and array accesses at run time. Guards maintain attributes to catch out of bounds array accesses and accesses to deallocated memory. Our system has found a number of previously unreported errors in widely-used Unix utilities and SPEC92 benchmarks. Many commonly used programs have bugs which may not always manifest themselves as a program crash, but may instead produce a subtly wrong answer. These programs are not routinely checked for run-time errors because the increase in execution time due to run-time checking can be very high. We present two techniques to handle the high cost of run-time checking of pointer and array accesses in C programs: ‘customization’ and ‘shadow processing’. Customization works by decoupling run-time checking from original computation. A user program is customized for guarding by throwing away computation not relevant for guarding. We have explored using program slicing for customization. Customization can cut the overhead of guarding by up to half. Shadow processing uses idle processors in multiprocessor workstations to perform run-time checking in the background. A user program is instrumented to obtain a ‘main process’ and a ‘shadow process’. The main process performs computations from the orignal program, occasionally communicating a few key values to the shadow process. The shadow process follows the main process, checking pointer and array accesses. The overhead to the main process which the user sees is very low – almost always less than 10%. © 1997 by John Wiley & Sons, Ltd.

Is meaning implicated in illusory conjunctions?

According to feature-integration theory, when attention is diverted from a display, features from different objects in that display may be wrongly recombined, giving rise to "illusory conjunctions" (Treisman & Schmidt, 1982). Two experiments are reported that examine the nature of these illusory conjunctions. In displays that contain color names and adjectives printed in colored ink, subjects made two kinds of interesting and previously unreported errors. Consider, for example, a display that included the word BROWN in red ink and the word HEAVY in green ink. Subjects would sometimes incorrectly report that the word RED or the ink color brown had appeared in the display (e.g., RED in green ink or HEAVY in brown ink). It appears that subjects extract semantic representations from input and are sometimes confused about whether a particular representation has been extracted from a word or a color patch. Contrary to feature-integration theory, these findings suggest that illusory conjunctions may occur with high-level codes as well as with perceptual features.

Is meaning implicated in illusory conjunctions?

According to feature-integration theory, when attention is diverted from a display, features from different objects in that display may be wrongly recombined, giving rise to "illusory conjunctions" (Treisman & Schmidt, 1982). Two experiments are reported that examine the nature of these illusory conjunctions. In displays that contain color names and adjectives printed in colored ink, subjects made two kinds of interesting and previously unreported errors. Consider, for example, a display that included the word BROWN in red ink and the word HEAVY in green ink. Subjects would sometimes incorrectly report that the word RED or the ink color brown had appeared in the display (e.g., RED in green ink or HEAVY in brown ink). It appears that subjects extract semantic representations from input and are sometimes confused about whether a particular representation has been extracted from a word or a color patch. Contrary to feature-integration theory, these findings suggest that illusory conjunctions may occur with high-level codes as well as with perceptual features.