20 resultados para Analyses errors
em Doria (National Library of Finland DSpace Services) - National Library of Finland, Finland
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The purpose of this bachelor's thesis was to chart scientific research articles to present contributing factors to medication errors done by nurses in a hospital setting, and introduce methods to prevent medication errors. Additionally, international and Finnish research was combined and findings were reflected in relation to the Finnish health care system. Literature review was conducted out of 23 scientific articles. Data was searched systematically from CINAHL, MEDIC and MEDLINE databases, and also manually. Literature was analysed and the findings combined using inductive content analysis. Findings revealed that both organisational and individual factors contributed to medication errors. High workload, communication breakdowns, unsuitable working environment, distractions and interruptions, and similar medication products were identified as organisational factors. Individual factors included nurses' inability to follow protocol, inadequate knowledge of medications and personal qualities of the nurse. Developing and improving the physical environment, error reporting, and medication management protocols were emphasised as methods to prevent medication errors. Investing to the staff's competence and well-being was also identified as a prevention method. The number of Finnish articles was small, and therefore the applicability of the findings to Finland is difficult to assess. However, the findings seem to fit to the Finnish health care system relatively well. Further research is needed to identify those factors that contribute to medication errors in Finland. This is a necessity for the development of methods to prevent medication errors that fit in to the Finnish health care system.
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Diplomityö käsittelee kiehutusvesilaitosten transienttien ja onnettomuuksien analysointia APROS-ohjelmiston avulla. Työ on tehty Teollisuuden Voima Oy:n (TVO) Olkiluoto 1 ja 2 laitosyksiköiden mallin pohjalta. Raportissa esitetään ohjelmiston käyttämiä yhtälöitäja laskentamalleja yleisellä tasolla. Työssä esitellään laitoksen yleispiirteet turvallisuustoimintoineen ja kuvataan ohjelmaan suureksi osaksi aiemmin luotua laskentamallia. Työssä on luetteloitu voimassa olevatlisensiointianalyysit, joiden joukosta on valittu laskentatapauksia ohjelmiston suorituskyvyn arviointia varten. Lisäksi työhön on valittu laskentatapauksia muilla kuin lisensointiin käytetyillä ohjelmilla lasketuista analyyseistä. Lisäksi on suoritettu vertailulaskuja konservatiivisen ja realistisen mallin erojen esille saamiseksi. Laskentatapauksia ovat mm. ylipainetransientti, jäähdytteen menetysonnettomuus ja oletettavissa oleva käyttöhäiriö, jossa pikasulku ei toimi (ATWS). Diplomityön edetessä laitosmallia on kehitetty edelleen lisäämällä joitakin järjestelmiä ja tarkentamalla joidenkin komponenttien kuvausta. Työssä ilmeni, että APROS soveltuu jäähdytteenmenetysonnettomuuden ja suojarakennuksen yhtäaikaiseen analyysiin. APROS.n vaste nopeisiin transientteihin jäi kuitenkin vertailutasosta. Tämän työn perusteella APROS-mallia kehitys jatkuu edelleen siten, että se soveltuisi entistä paremmin myös nopeiden transienttien ja ATWS-tilanteiden kuvaamiseen. Työssä olevaa lisensointianalyysien kuvausta tullaan käyttämään hyväksi selvitettäessä laitoksen turvallisuuden väliarviossa tarvittavien analyysien määrää ja laatua. Nyt saatuja kokemuksia voidaan hyödyntää myös mahdollisen kolmiulotteisen sydänmallin hankinnassa APROS-ohjelmistoon. Tässä diplomityössä esitettyjä parannuksia voidaan käyttää hyväksi SAFIRtutkimusohjelman hankkeiden suunnittelussa.
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Työn kohteena olivat Suomen öljytaseeseen liittyvät kansainväliset vuosikyselyt, joiden raportoinnista Suomessa vastaa Tilastokeskus. Samalla tarkasteltiin Tilastokeskuksen laatimia kansallisia energiatilastoja, jotka liittyvät öljyn hankintaan, jalostukseen ja käyttöön. Työn pääpaino oli kuitenkin kansainvälisissä raportoinneissa. Työn tavoitteena oli kehittää Eurostatin, IEA:n ja YK:n vuosittaisen öljykyselyn sekä YK:n ilmastosopimukselle laadittavaan kasvihuonekaasuinventaarioon liittyvän Reference Approach -laskennan raportointia. Selvitysten toivottiin pienentävän öljynhankinnan ja kulutuksen välisistä tase-eroista johtuvia tilastovirheitä. Kansainvälisten raportointien tutkimuksesta odotettiin myös löytyvän kehittämisehdotuksia kansallisiin energiatilastoihin. Vuosittaisten energiakyselyiden pohjalta syntyvät merkittävimmät kansainväliset energiatilastotietokannat. Tietoja käytetään useisiin tarkoituksiin muun muassa energian riittävyyden jakulutuksen analysointiin globaalisti. Reference Approach on taas vaihtoehtoinenlaskentatapa energiakäytöstä ja -tuotannosta aiheutuville hiilidioksidipäästöille. Reference Approach raportoidaan vuosittain YK:n ilmastosopimukselle. Työ toteutettiin tarkastelemalla kansainvälisen öljykyselyn rakennetta ja useista eri lähteistä saatuja öljytuotteiden lähtötietoja. Vuoden 2004 öljykyselyä täydennettiin ja tietoja verrattiin alkuperäiseen raporttiin. Reference Approach -laskennan tutkiminen toteutettiin tarkistamalla öljytuotteiden lähtötiedot ja loppukäytön jakaantuminen energiakäytön ja raaka-ainekäytön välillä. Tutkimuksien pohjalta Reference Approach -aikasarja laskettiin uudelleen ja tuloksia verrattiin alkuperäiseen aikasarjaan. Työn tuloksena saatiin sekä kansainvälistä öljykyselyä että Reference Approach -laskentaa tarkennettua huomattavasti. Samalla tilastovirheet pienenivät merkittävästi. Työssä tehtyjä havaintoja ja tuloksia tullaan hyödyntämään jatkossa sekä Suomen kasvihuonekaasupäästöjen laskennassa että kansainvälisen öljykyselyn raportoinnissa.
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The market place of the twenty-first century will demand that manufacturing assumes a crucial role in a new competitive field. Two potential resources in the area of manufacturing are advanced manufacturing technology (AMT) and empowered employees. Surveys in Finland have shown the need to invest in the new AMT in the Finnish sheet metal industry in the 1990's. In this run the focus has been on hard technology and less attention is paid to the utilization of human resources. In manymanufacturing companies an appreciable portion of the profit within reach is wasted due to poor quality of planning and workmanship. The production flow production error distribution of the sheet metal part based constructions is inspectedin this thesis. The objective of the thesis is to analyze the origins of production errors in the production flow of sheet metal based constructions. Also the employee empowerment is investigated in theory and the meaning of the employee empowerment in reducing the overall production error amount is discussed in this thesis. This study is most relevant to the sheet metal part fabricating industrywhich produces sheet metal part based constructions for electronics and telecommunication industry. This study concentrates on the manufacturing function of a company and is based on a field study carried out in five Finnish case factories. In each studied case factory the most delicate work phases for production errors were detected. It can be assumed that most of the production errors are caused in manually operated work phases and in mass production work phases. However, no common theme in collected production error data for production error distribution in the production flow can be found. Most important finding was still that most of the production errors in each case factory studied belong to the 'human activity based errors-category'. This result indicates that most of the problemsin the production flow are related to employees or work organization. Development activities must therefore be focused to the development of employee skills orto the development of work organization. Employee empowerment gives the right tools and methods to achieve this.
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Electric motors driven by adjustable-frequency converters may produce periodic excitation forces that can cause torque and speed ripple. Interaction with the driven mechanical system may cause undesirable vibrations that affect the system performance and lifetime. Direct drives in sensitive applications, such as elevators or paper machines, emphasize the importance of smooth torque production. This thesis analyses the non-idealities of frequencyconverters that produce speed and torque ripple in electric drives. The origin of low order harmonics in speed and torque is examined. It is shown how different current measurement error types affect the torque. As the application environment, direct torque control (DTC) method is applied to permanent magnet synchronous machines (PMSM). A simulation model to analyse the effect of the frequency converter non-idealities on the performance of the electric drives is created. Themodel enables to identify potential problems causing torque vibrations and possibly damaging oscillations in electrically driven machine systems. The model is capable of coupling with separate simulation software of complex mechanical loads. Furthermore, the simulation model of the frequency converter's control algorithm can be applied to control a real frequency converter. A commercial frequencyconverter with standard software, a permanent magnet axial flux synchronous motor and a DC motor as the load are used to detect the effect of current measurement errors on load torque. A method to reduce the speed and torque ripple by compensating the current measurement errors is introduced. The method is based on analysing the amplitude of a selected harmonic component of speed as a function oftime and selecting a suitable compensation alternative for the current error. The speed can be either measured or estimated, so the compensation method is applicable also for speed sensorless drives. The proposed compensation method is tested with a laboratory drive, which consists of commercial frequency converter hardware with self-made software and a prototype PMSM. The speed and torque rippleof the test drive are reduced by applying the compensation method. In addition to the direct torque controlled PMSM drives, the compensation method can also beapplied to other motor types and control methods.
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The underlying cause of many human autoimmune diseases is unknown, but several environmental factors are implicated in triggering the self-destructive immune reactions. Multiple Sclerosis (MS) is a chronic autoimmune disease of the central nervous system, potentially leading to persistent neurological deterioration. The cause of MS is not known, and apart from immunomodulatory treatments there is no cure. In the early phase of the disease, relapsing-remitting MS (RR-MS) is characterized by unpredictable exacerbations of the neurological symptoms called relapses, which can occur at different intervals ranging from 4 weeks to several years. Microbial infections are known to be able to trigger MS relapses, and the patients are instructed to avoid all factors that might increase the risk of infections and to properly use antibiotics as well as to take care of dental hygiene. Among those environmental factors which are known to increase susceptibility to infections, high ambient air inhalable particulate matter levels affect all people within a geographical region. During the period of interest in this thesis, the occurrence of MS relapses could be effectively reduced by injections of interferon, which has immunomodulatory and antiviral properties. In this thesis, ecological and epidemiological analyses were used to study the possible connection between MS relapse occurrence, population level viral infections and air quality factors, as well as the effects of interferon medication. Hospital archive data were collected retrospectively from 1986-2001, a period in time ranging from when interferon medication first became available until just before other disease-modifying MS therapies arrived on the market. The grouped data were studied with logistic regression and intervention analysis, and individual patient data with survival analysis. Interferons proved to be effective in the treatment of MS in this observational study, as the amount of MS exacerbations was lower during interferon use as compared to the time before interferon treatment. A statistically significant temporal relationship between MS relapses and inhalable particular matter (PM10) concentrations was found in this study, which implies that MS patients are affected by the exposure to PM10. Interferon probably protected against the effect of PM10, because a significant increase in the risk of exacerbations was only observed in MS patients without interferon medication following environmental exposure to population level specific viral infections and PM10. Apart from being antiviral, interferon could thus also attenuate the enhancement of immune reactions caused by ambient air PM10. The retrospective approach utilizing carefully constructed hospital records proved to be an economical and reliable source of MS disease information for statistical analyses.
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In mammals, post-testicular sperm maturation taking place in the epididymis is required for the spermatozoa to acquire the abilities required to fertilize the egg in vivo. The epididymal epithelial cells secrete proteins and other small molecules into the lumen, where they interact with the spermatozoa and enable necessary maturational changes. In this study different in silico, in vitro and in vivo approaches were utilized in order to find novel genes responsible for the function of the epididymis and post-testicular sperm maturation in the mouse. Available online genomic databases were analyzed to identify genes potentially expressed in the epididymis, gene expression profiling was performed by studying their expression in different mouse tissues, and significance of certain genes to fertility was assessed by generating genetically modified mouse models. A recently discovered Pate (prostate and testis expression) gene family was found to be predominantly expressed in the epididymis. It represents one of the largest known gene families expressed in the epididymis, and the members code for proteins potentially involved in defense against microorganisms. Through genetically modified mouse models CRISP4 (cysteine-rich secretory protein 4) was identified to regulate sperm acrosome reaction, and BMYC to inhibit the expression of the Myc proto-oncogene in the developing testis. A mouse line expressing iCre recombinase specifically in the epididymis was also generated. This model can be used to generate conditional, epididymis-specific knock-out models, and will be a valuable tool in fertility studies.