Wrong Rate Research Articles

211: Identifying magnesium sulfate errors on an inpatient obstetrics unit

Magnesium sulfate is one of the most commonly used medications in obstetrics and its use is often in high-risk, high-acuity patients. The Institute for Safe Medication Practices classifies magnesium sulfate as a high-alert medication which has potential to cause significant harm if used in error. The objective of this quality improvement study was to describe magnesium sulfate errors in our inpatient obstetrics unit. We performed a retrospective analysis of all medication errors involving magnesium sulfate from January 1, 2016 to December 31, 2018 using the institution’s centralized risk management event reporting system. Our multidisciplinary quality improvement team utilized process mapping to outline the workflow from medication ordering to administration for magnesium sulfate and then classified and superimposed all magnesium errors by process step onto our process map in order to identify areas to target for improvement. During the time analyzed there were twenty-eight magnesium errors reported. Errors occurred most frequently during medication administration (n=17). The wrong infusion rate was the most frequent administration error (n=7), with 3 of these errors leading to harm (Figure 1). Figure 2 depicts the process map generated by our team. The green circles indicate the number of errors occurring at that specific process step. This study demonstrates how a multidisciplinary quality improvement process can be utilized to address medication errors on labor & delivery units. We identified administration errors, specifically wrong infusion rate, as a significant portion of magnesium errors at our institution with real potential to cause harm. This information has helped our team develop a new protocol for magnesium administration with safeguards built in to prevent these types of errors from occurring. We will be tracking post protocol implementation error rates to determine the success of these changes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

212: Medication events leading to patient harm in an inpatient obstetrics unit

According to a report by the Institute of Medicine the average hospitalized patient in the U.S. experiences one medication error every day. Many medications used frequently in obstetrics are classified as high-alert by the Institute for Safe Medication Practices (ISMP) however evaluation of their safe use in practice is largely unknown. The objective of this quality improvement study was to describe errors resulting in patient harm and determine the frequency of patient harm from high-alert medications in our high-risk inpatient obstetrics unit. We performed a retrospective analysis of all medication errors from January 1, 2014 to July 1, 2019 using our institution’s centralized risk management event reporting system. Utilizing the error severity classification system (A–unsafe condition no event, B–Near miss, C-No harm, reached patient no monitoring, D–No harm, reached patient monitoring required, E–Harm, temporary intervention needed & F–Harm, temporary hospitalization/higher level of care needed) we assessed all medication errors with harm events (E & F). All errors were evaluated by event and medication type. During the time analyzed there were 18 medication errors resulting in patient harm. Figure 1 depicts the number of harm events by medication and event type. Magnesium sulfate had the most harm events (n=5) followed by regular insulin (n=2), bupivacaine with sufentanil epidurals (n=2), and gentamicin (n=2). A variety of process steps lead to harm events. Administering an IV infusion medication at the wrong rate was the cause of most errors (n=5) followed by inappropriate doses (n=4) and missed doses (n=3). The 3 most frequent medications leading to harm are listed as high-alert by ISMP. High-alert medications represented 10 of the 18 harm events (Figure 2). Our analysis demonstrates that, although infrequent, medication events leading to patient harm occur in our obstetrics unit. ISMP high-alert drugs were involved in 55% of harm events. These high-alert medications should be prioritized by quality improvement initiatives to reduce errors.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Risk of Medication Errors With Infusion Pumps

The risk of medication errors with infusion pumps is well established, yet a better understanding is needed of the scenarios and factors associated with the errors. Our study explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018. Our study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, we did find that 22% of events involved a high-alert medication. Our study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, we manually reviewed a free-text narrative field in each event report to better understand the nature of errors. For example, we found that a majority of wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.

The Use of Smartphone-Based Triage to Reduce the Rate of Outpatient Error Registration: Cross-Sectional Study.

BackgroundIn many clinics, patients now have the option to make Web-based appointments but doing so according to their own judgment may lead to wrong registration and delayed medical services. We hypothesized that smartphone-based triage in outpatient services is superior to Web-based self-appointment registration guided by the medical staff.ObjectiveThis study aimed to investigate smartphone-based triage in outpatient services compared with Web-based self-appointment registration and to provide a reference for improving outpatient care under appointment registration.MethodsThe following parameters in Guangzhou Women and Children’s Medical Center were analyzed: wrong registration rate, the degree of patient satisfaction, outpatient visits 6 months before and after smartphone-based triage, queries after smartphone-based triage, number of successful registrations, inquiry content, and top 10 recommended diseases and top 10 recommended departments after queries.ResultsSmartphone-based triage showed significant effects on average daily queries, which accounted for 16.15% (1956/12,112) to 29.46% (3643/12,366) of daily outpatient visits. The average daily successful registration after queries accounted for 56.14% (1101/1961) to 60.92% (1437/2359) of daily queries and 9.33% (1130/12,112) to 16.83% (2081/12,366) of daily outpatient visits. The wrong registration rate after smartphone-based triage was reduced from 0.68% (12,810/1,895,829) to 0.12% (2379/2,017,921) (P<.001), and the degree of patient satisfaction was improved. Monthly outpatient visits were increased by 0.98% (3192/325,710) to 13.09% (42,939/328,032) compared with the same period the preceding year (P=.02).ConclusionsSmartphone-based triage significantly reduces the wrong registration rate caused by patient Web-based appointment registration and improves the degree of patient satisfaction. Thus, it is worth promoting.

Analysis and research on quality control method of global radiation observation data

Radiation observation data are important basic data for assessment and research of climate change and solar energy resources. Quality control of radiation observation data is an important guarantee for accurate and reliable observation. First, the global radiation data collection method and the quality control process are introduced, and the differences and similarities between different quality control standards are compared in detail. Then, the quality control contents of the upper and lower limits and the rate of change are analysed theoretically and verified by experiments. Theoretical analysis and experimental results showed that the lower limit of the global radiation irradiance quality control should be −20 W/m2, the upper limit should be 2221 W/m2 or based on solar position, and the wrong change rate of sampling value should be 1000 W/m2. Through the unification of the global radiation quality control standards, the difference caused by the inconsistent quality control methods can be avoided, thus improving the effectiveness of the radiation observation data and ensuring the accuracy and consistency of the radiation observation data.

RADIATION AWARENESS AMONG FIFTH CLASS MEDICAL STUDENTS

AMAÇ: Bu çalışmada, yakın geleceğin hekim adayları olan 5. sınıf tıp fakültesi öğrencilerinde radyasyon farkındalığını değerlendirmek ve bu konuya ilgi çekmek amaçlandı.GEREÇ VE YÖNTEM: Eskişehir Osmangazi Üniversitesi Tıp Fakültesi 5. sınıf 50 öğrenciye radyasyon kaynakları, radyolojik tetkikler, radyasyondan korunma ile ilgili toplam 10 çoktan seçmeli sorudan oluşan anket gözlem altında uygulandı. Anketten elde edilen sonuçlar doğru ve yanlış cevapların dağılımı şeklinde değerlendirildi.BULGULAR: Çalışmaya 23 kadın (22-24 yaş, ortalama yaş 23.08), 27 erkek (22-30 yaş, ortalama yaş 23.11) toplam 50 öğrenci katıldı. Katılımcıların tüm sorulara verdikleri doğru cevap oranı % 70.4, yanlış cevap oranı % 29.6 idi. En yüksek oranda doğru cevap verilen soru gama ışınlarının iyonlaştırıcı radyasyon kaynağı olduğudur. En fazla yanlış cevap verilen soru ise gelişmiş ülkelerde maruz kalınan iyonizan radyasyonun en büyük kaynağının doğal radyasyon olduğudur.SONUÇ: Radyasyon kaynakları, biyolojik etkileri, radyasyondan korunma yöntemleri ve radyolojik algoritma tıp fakültesi eğitiminde daha fazla önem verilmesi gereken konulardır.

Medication Errors and Their Relationship with Care Complexity and Work Dynamics.

BACKGROUND:Medication errors are currently known as the most common medical errors. Research shows that work environment and organisation management, in addition to the role of nurses, contribute to the occurrence of an error.AIM:Therefore, the present study was conducted to determine the rate of nurses’ medication errors and its relation to the care complexity and work dynamics in the Taleghani Pediatric Hospital of Gorgan in 2017.MATERIAL AND METHODS:This was a descriptive-correlational and cross-sectional study. Sampling was done through census method (N = 100). The data collection tools consisted of four questionnaires of demographic information, Salyer work dynamics, Medication Administration Errors, and Velasquez Nursing Care Complexity. Data were analysed in SPSS V.16 software using descriptive and inferential statistical methods including independent t-test and Pearson’s correlation.RESULTS:Medication calculation errors, wrong dose and wrong medication were the most common non-injectable medication errors, respectively. Drug incompatibility, wrong infusion rate and medication calculation errors were the most common injectable medication errors, respectively. There was a positive correlation between medication calculation errors (P = 0.02, r = 0.23), wrong solvent (P = 0.04, r = 0.21), and drug incompatibility (P = 0.01, r = 0.25) with amount of work dynamics. Also, there was a positive correlation between medication calculation errors (P = 0.03, r = 0.22) and wrong medication (P = 0.00, r = 0.31) with the nursing care complexity.CONCLUSION:Regarding the irrefutable impact of working conditions on the occurrence of errors, it appears that the study and complete recognition of nurses’ working conditions and their adjustment would lead to a reduction in medication errors.

Prediction Model for Financial Distress Using Proposed Data Mining Approach

The problem of financial distress researches are the lack of awareness of banks about the risks of financial failure and its impact on the continuity of its activity in the future, as the traditional methods used to predict financial failure through financial analysis based on financial ratios in a single result gives misleading results cannot be relied upon to judge the continuity of the activity of banks, With an increase in the number of failed banks and their inability to continue. Which requires the discovery of modern techniques that serve as an early warning of the possibility of failure and lack of continuity. The research aims to apply data mining technology to predict the financial failure of banks, and how it can provide information that helps to judge the extent to which banks continue to operate. This effort suggested founded back propagation artificial neural network to build predict system. The proposed module evaluated with banks fromFree Iraq Stock Exchange dataset the investigational outcomes displays capable method to identify failure banks with great discovery rate and small wrong terror rate.

Magnitude of error: a review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system

ObjectivesOur aim was to review medication-related incidents reported to a hospital voluntary incident reporting system to identify and quantify the magnitude of wrong dose errors.MethodsThe study was a retrospective review...

Improving Intravenous Medication Administration and Reducing Medication Errors Among Critical Care Nurses at Jordan University Hospital

Background: Medication errors represent a serious problem in the hospital setting and remain a challenge to navigate among hospitalized patients in all departments. Mistakes in medication administration are considered a significant issue that threatens a patient’s safety and may increase their hospital stay, treatment costs, and mortality rate. Medication errors commonly committed by nurses may include medication preparation or administration errors, which are associated with the highest risk areas in nursing practice. Methodology: A pretest-posttest, quasi-experimental, the observational design was used. Convenience sampling was employed to include all intravenous medication errors committed by nurses in three ICUs of Jordan University Hospital (pretest: 236 errors and post-test: 68 errors, respectively). A designed incident report was used for data collection. Data collection was carried out simultaneously in the three ICUs during nurses’ preparation and administration of intravenous medications over two months for pretest and posttest data (May and June 2018). A tailored evidenced-based educational program designed using Phillips's Manual of I. V. Therapeutics: Evidence-based Practice for Infusion Therapy was furnished to all registered nurses utilizing structured classroom lectures and on-the-job training; moreover, educational medals of common medications and illustration posters were used as additional reminders.Results and Conclusion: More than half of nurses were females and held bachelor’s degrees. Half of the observed medication errors were identified in the surgical ICU. Intravenous medication errors observed during the day shift were significantly higher in number than those in the night shift. A significant reduction in the number of medication errors was noted after the implementation of a bundle of interventions (i.e., there was a reduction from 236 errors to 68 errors). Giving (1) an omeprazole push and then (2) administering vancomycin rapidly thereafter, followed by (3) administering omeprazole at the wrong time, were the three most observed medication errors in the ICUs. Most medication errors were not reported officially using incident reports. Based on the category of the intravenous medication error, ‘wrong medication rate’ followed by ‘wrong medication time’, and then ‘mixing the medication with another drug’ were the most prominent errors noticed. The rate of reported medication errors was significantly higher after program implementation. An ongoing surveillance system is required to monitor intravenous medication errors and to know the causes to find a solution to further decrease them and their consequences. Also, all nurses should receive an intensive specialized evidence-based educational program about medication handling, utilizing clinical training, and frequent reminding.

CE: Original Research: Errors in Postoperative Administration of Intravenous Patient-Controlled Analgesia: A Retrospective Study.

Relevant data were collected from the medical records of all patients who received IV PCA at a large academic medical center in South Korea during a three-year period. The study sample comprised 45,104 patients who used one of four types of IV PCA delivery devices. Errors occurred in 406 cases (0.9%). Operator error was the most common type of error (54.7%), followed by device malfunction (32.3%), prescription error (12.3%), and patient error (0.7%). Of the 222 operator errors, the most frequent type was failure to begin IV PCA drug administration (28.8%), followed by programming errors by non-anesthesia providers who weren't authorized to program the device (24.8%) and wrong infusion rates set by anesthesia providers who were so authorized (24.8%). The findings provide valuable information that can aid in the development of policy and procedures for safer, more effective postoperative administration of IV PCA. They also suggest that it's necessary not only to improve the operation of acute pain services teams, but also to ensure ongoing provider and patient education specific to IV PCA use.

PIN1 - Prevalence, Potential Clinical Outcome and Risk Factors of Medication Errors Related to Antibiotics’ Preparation and Administration by Nurses in a University Hospital

Little is known about medication errors (MEs) related to antibiotics in Vietnamese hospitals. The study aimed to determine the prevalence, potential clinical outcome and factors associated with MEs related to antibiotics during preparation and administration by nurses. A 3-week prospective study was conducted on three clinical wards (Cardiovascular Medicine, Internal Medicine and Gastroenterology Surgery) at a university hospital. Data were collected by direct observation of nurses’ preparation and administration by two pharmacists during 11 hours per day on 7 consecutive days on each ward. Potential clinical outcomes of MEs are evaluated by the modified National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index by consensus of two pharmacists. Regression analyses were conducted to identify risk factors of MEs. There was totally 82.7% of 992 doses of antibiotics had at least one error. All 1724 MEs were related to injectable antibiotics. Wrong – rate was the highest error rate (41.7%), then wrong preparation technique, wrong – time, and incompatibility were 29.2%, 20.7%, and 8.1%, respectively. There were 77.1% potentially harmful MEs. Complex preparation procedure (p < 0.01) was the risk factor related to MEs. The high rate of errors were observed in injectable antibiotics, mainly due to wrong rate and wrong preparation techniques. Strategies for improvement should be focused on risk factors and potentially harmful MEs.

Caliber Corrected Markov Modeling (C2M2): Correcting Equilibrium Markov Models.

Rate processes are often modeled using Markov State Models (MSMs). Suppose you know a prior MSM and then learn that your prediction of some particular observable rate is wrong. What is the best way to correct the whole MSM? For example, molecular dynamics simulations of protein folding may sample many microstates, possibly giving correct pathways through them while also giving the wrong overall folding rate when compared to experiment. Here, we describe Caliber Corrected Markov Modeling (C2M2), an approach based on the principle of maximum entropy for updating a Markov model by imposing state- and trajectory-based constraints. We show that such corrections are equivalent to asserting position-dependent diffusion coefficients in continuous-time continuous-space Markov processes modeled by a Smoluchowski equation. We derive the functional form of the diffusion coefficient explicitly in terms of the trajectory-based constraints. We illustrate with examples of 2D particle diffusion and an overdamped harmonic oscillator.

Nurses’ Medication Administration Errors at Medical Surgical Units

Medication administration errors (MAEs) are among the key concepts of patient safety in clinical care settings that have long been the focus of study and exploration because they contribute directly to patient injury, death and health care costs. Medication errors are recurrent and expected to be a prolonged problem in the health care system. The administration of medication is predominantly an important part of nursing practice that has a dimension of quality of care and organizational performance. The study sought to assess nurses’ medication administration errors at the general medical and surgical units. A descriptive cross sectional study design was used where stratified random sampling using the medical and surgical units as strata was used to proportionately recruit 100 Nurses. Each nurse was further observed twice during medication administration process making a total of 200 observations included in the study. Two tools were used to collect data for the current study. The interviewer administered medication administration errors questionnaire and a concealed medication administration observation checklist. Data was collected for a period of four months and analyzed using descriptive and inferential statistics to check for relations between variables. The study findings imply that the wrong rate of administration, the wrong time of administration and medication being administered after the order to discontinue was written were the highly perceived MAEs reported respectively as occurring ‘most of the time’ by 27%, 23% and 15% of the studied nurses. For observed MAEs, the wrong time error type had the highest estimated error rate of 51%, followed by the documentation error at 29% and technique error at 27.5%. There was statistical significant difference between the pharmacy reasons subscale of causes of MAEs and the age (F= 5.465, p=0.006), clinical experience (F=3.922, p=0.011) and type of shift (F=2.507, p=0.035) the nurse works most. Further, there was statistically significant mean differences between the medical and surgical units with regard to the medication packaging subscale (t=4.160, p=0.044). The findings also revealed negative significant correlation between the observed MAEs scores and the nurses’ reported scores on types of IV & non-IV MAEs (r_s=-0.266, p=0.007) and the pharmacy reasons subscale (r_s=-0.266, p=0.046). Updating, developing, disseminating and implementing medication administration guidelines and protocols in the hospital settings is required. Nurses have to embrace the occurrence of MAEs as a patient safety indicator that should be viewed as an opportunity to learn and prevent MAEs through rationalized medication management protocols and guidelines.

A Note on High-Precision Approximation of Asymptotically Decaying Solution and Orthogonal Decomposition

In some physical applications, the decaying rate of asymptotically decaying solution is more important than the solution magnitude itself in understanding the physical system such as the late-time behavior of decaying fields in black hole space-time. In Khanna (J Sci Comput 56(2):366–380, 2013), it was emphasized that high-precision arithmetic and high-order methods are required to capture numerically the correct decaying rate of the late-time radiative tails of black-hole system in order to prevent roundoff errors from inducing a wrong power-law decay rate in the numerical approximation. In this paper, we explain how roundoff errors induce a wrong decay mode in the numerical approximation using simple linear differential equations. Then we describe the orthogonal decomposition method as a possible technique to remove wrong decaying modes induced by roundoff errors in the numerical approximation.

Effect of core-shell structure on optical properties of Au-Cu2O nanoparticles

Solid Au-Cu2O core-shell nanoparticles were synthesized using gold nanoparticles of 16.6nm in size as the core. The core-shell structure of the synthesized particles was confirmed and characterized by TEM and HRTEM images. Due to their similar crystal structure, the (111) planes of Cu2O are nucleated and grown epitaxially on the {111} facets of Au nanoparticles with the lattice mismatch of about 4.3% resulting in a polycrystallized Cu2O shell covering the Au nanocore. Due to the quantum confinement effect, the band gap energy Eg of the synthesized Cu2O shells is blue-shifted from 2.35 to 2.70eV as the shell thickness decreases from of 24.6±3.6 to 9.0±1.7nm. The localized SPR (Surface Plasmon Resonance) peak of the Au nanocore undergoes a large red shift of the order of a hundred of nm due to both the high refractive index and the increase of the thickness of Cu2O shell. Theoretical models within the Drude framework significantly underestimate the experimental data and predict a wrong rate of change of the SPR peak position with respect to the shell thickness.

Quality of network direct reporting of information about intervention service in population at high risk for HIV infection in China, 2013-2014

Objective: To analyze the problems in the network direct reporting of information about intervention service conducted in population at high risk for HIV infection in China during 2013-2014, and provide evidence for the improvement of the network direct reporting of the intervention information. Methods: The wrong records of the intervention service in population at high-risk were collected from national AIDS prevention and treatment information system. The wrong records, including those found at county (district) level and those found at state level, were analyzed with descriptive statistical method. Results: A total of 1 066 wrong records were found during 2013-2014, and average annual wrong record rate was <0.1%. Up to 71.3% (760/1 066) of wrong records occurred in the first half year. The wrong records in eastern, central and western areas accounted for 14.9% (159/1 066), 22.6% (241/1 066) and 62.5% (666/1 066) of the total respectively. More wrong records were found in the intervention information for men who have sex with men and injecting drug users than in those for female sex workers. Among the total wrong records, 86.4% (921/1 066) were found at county level and 13.6% (145/1 066) were found at state level. The wrong records were mainly"annual number of persons receiving the first HIV test"and"annual number of persons covered by intervention". Common causes of wrong records were underreporting and delay, staff fault, miscalculation and misunderstanding. Conclusion: In general, the wrong record rate in intervention information for population at high risk for HIV infection reported directly through network was low in China. It is necessary to strengthen the recording of the intervention service, the quality control of statistics and network direct reporting and staff training to improve the quality of reported data of intervention service.

Research on choices of spectral bins in energy-based frequency estimators under intensive noise

This paper presented the problem of wrong choice of spectral bins in the energy-based frequency estimation method under intensive noise, and studied its impact on the frequency estimation. Based on the theory of energy-based method, the causes for wrong location of spectral bins in the traditional estimation method were analyzed. In order to reduce wrong choice rate of spectral bins, two optimizational location strategies of spectral bins were introduced, and the effects of them were confirmed by computer simulation. A numerical test under intensive noise was carried out, in which estimation errors returned by optimizational spectral location strategies were compared. It was demonstrated that the estimation accuracy under intensive noise can be remarkably improved by using optimizational spectral location strategies. In particular, Macleod’s optimizational strategy is strongly suggested because of its prominent advantage in reducing occurrences of wrong location as well as its best performance in frequenc...

Right or wrong collision rate analysis without profiling: full-automatic collision fault attack

In CHES 2010, Fault Sensitivity Analysis (FSA) on Advanced Encryption Standard (AES) hardwarecircuit based on S-box setup-time acquired by injecting clock glitches is proposed.Soon after, some improvements of FSA were presented such as colliding timing characteristics from Moradi et al.However, the acquisition of timing characteristicsrequires complex procedure due to the very gradual decrease of clock glitch cycleand the heavy requirements of setup-time samples.In HOST 2015, Wang et al. presented template-based right or wrong collision rate attack to improve the efficiency of FSA,but its profiling and plaintexts-choice procedures required too many encryptions.In this paper, we fix only one specific clock glitch cycle,and take the right or wrong collision rate as a collision distinguisher.So, the whole process is a non-profiling collision attack which can be executed automaticallywithout massive pre-computations and interactions between PC and signal generator.According to the experiments, 256 encryptions are enough for exactly decidingwhether two plaintext bytes can induce an S-box collision.Compared with the existing power analysis and FSA-based attacks on AES hardware,it costs negligible time (about 6.65 s) and storage space (only one byte), and no offline computationsfor finding the collision between two masked S-boxes.Furthermore, our study shows that the signal-to-noise ratio in FSA-based attacksis much higher than power-based attacks.

Why Do Borrowers Make Mortgage Refinancing Mistakes?

Refinancing a mortgage is often one of the most important financial decisions people make. Borrowers choose the interest rate differential at which to refinance, and when that differential is reached, they need to take the steps to refinance before rates change again. Using a simple closed-form solution approximation of the optimal refinancing rule and a unique panel data set including information from a large secondary market participant on refinancing, we find that approximately 57% of borrowers refinance suboptimally—50% choose the wrong rate, 17% wait too long to refinance, and 10% do both. Financially sophisticated borrowers make smaller mistakes, refinancing at rates closer to optimal and waiting less after mortgage rates reach their trigger rates. Evidence suggests borrowers learn from their refinancing experiences. This paper was accepted by Amit Seru, finance.