Oops! Another medication error : a literature review of contributing factors and methods to prevent medication errors

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.

Minimum error contrast enhancement

Contrast enhancement is an image processing technique where the objective is to preprocess the image so that relevant information can be either seen or further processed more reliably. These techniques are typically applied when the image itself or the device used for image reproduction provides poor visibility and distinguishability of different regions of interest inthe image. In most studies, the emphasis is on the visualization of image data,but this human observer biased goal often results to images which are not optimal for automated processing. The main contribution of this study is to express the contrast enhancement as a mapping from N-channel image data to 1-channel gray-level image, and to devise a projection method which results to an image with minimal error to the correct contrast image. The projection, the minimum-error contrast image, possess the optimal contrast between the regions of interest in the image. The method is based on estimation of the probability density distributions of the region values, and it employs Bayesian inference to establish the minimum error projection.

Origins of production errors and significance of employee empowerment in reducing production error amount in sheet metal fabricating industry

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.

Evaluation of Software Development Practices through Error Analysis

This thesis studies evaluation of software development practices through an error analysis. The work presents software development process, software testing, software errors, error classification and software process improvement methods. The practical part of the work presents results from the error analysis of one software process. It also gives improvement ideas for the project. It was noticed that the classification of the error data was inadequate in the project. Because of this it was impossible to use the error data effectively. With the error analysis we were able to show that there were deficiencies in design and analyzing phases, implementation phase and in testing phase. The work gives ideas for improving error classification and for software development practices.

Error Modeling and Accuracy Analysis of a Novel Mobile Hybrid Parallel Robot

Over the last decades, calibration techniques have been widely used to improve the accuracy of robots and machine tools since they only involve software modification instead of changing the design and manufacture of the hardware. Traditionally, there are four steps are required for a calibration, i.e. error modeling, measurement, parameter identification and compensation. The objective of this thesis is to propose a method for the kinematics analysis and error modeling of a newly developed hybrid redundant robot IWR (Intersector Welding Robot), which possesses ten degrees of freedom (DOF) where 6-DOF in parallel and additional 4-DOF in serial. In this article, the problem of kinematics modeling and error modeling of the proposed IWR robot are discussed. Based on the vector arithmetic method, the kinematics model and the sensitivity model of the end-effector subject to the structure parameters is derived and analyzed. The relations between the pose (position and orientation) accuracy and manufacturing tolerances, actuation errors, and connection errors are formulated. Computer simulation is performed to examine the validity and effectiveness of the proposed method.

Design and Analysis of Forward Error Control Coding and Signaling for Guaranteeing QoS in Wireless Broadcast Systems

Broadcasting systems are networks where the transmission is received by several terminals. Generally broadcast receivers are passive devices in the network, meaning that they do not interact with the transmitter. Providing a certain Quality of Service (QoS) for the receivers in heterogeneous reception environment with no feedback is not an easy task. Forward error control coding can be used for protection against transmission errors to enhance the QoS for broadcast services. For good performance in terrestrial wireless networks, diversity should be utilized. The diversity is utilized by application of interleaving together with the forward error correction codes. In this dissertation the design and analysis of forward error control and control signalling for providing QoS in wireless broadcasting systems are studied. Control signaling is used in broadcasting networks to give the receiver necessary information on how to connect to the network itself and how to receive the services that are being transmitted. Usually control signalling is considered to be transmitted through a dedicated path in the systems. Therefore, the relationship of the signaling and service data paths should be considered early in the design phase. Modeling and simulations are used in the case studies of this dissertation to study this relationship. This dissertation begins with a survey on the broadcasting environment and mechanisms for providing QoS therein. Then case studies present analysis and design of such mechanisms in real systems. The mechanisms for providing QoS considering signaling and service data paths and their relationship at the DVB-H link layer are analyzed as the first case study. In particular the performance of different service data decoding mechanisms and optimal signaling transmission parameter selection are presented. The second case study investigates the design of signaling and service data paths for the more modern DVB-T2 physical layer. Furthermore, by comparing the performances of the signaling and service data paths by simulations, configuration guidelines for the DVB-T2 physical layer signaling are given. The presented guidelines can prove useful when configuring DVB-T2 transmission networks. Finally, recommendations for the design of data and signalling paths are given based on findings from the case studies. The requirements for the signaling design should be derived from the requirements for the main services. Generally, these requirements for signaling should be more demanding as the signaling is the enabler for service reception.

Novel Methods for Error Modeling and Parameter Identification of a Redundant Serial-Parallel Hybrid Robot

To obtain the desirable accuracy of a robot, there are two techniques available. The first option would be to make the robot match the nominal mathematic model. In other words, the manufacturing and assembling tolerances of every part would be extremely tight so that all of the various parameters would match the “design” or “nominal” values as closely as possible. This method can satisfy most of the accuracy requirements， but the cost would increase dramatically as the accuracy requirement increases. Alternatively, a more cost-effective solution is to build a manipulator with relaxed manufacturing and assembling tolerances. By modifying the mathematical model in the controller, the actual errors of the robot can be compensated. This is the essence of robot calibration. Simply put, robot calibration is the process of defining an appropriate error model and then identifying the various parameter errors that make the error model match the robot as closely as possible. This work focuses on kinematic calibration of a 10 degree-of-freedom (DOF) redundant serial-parallel hybrid robot. The robot consists of a 4-DOF serial mechanism and a 6-DOF hexapod parallel manipulator. The redundant 4-DOF serial structure is used to enlarge workspace and the 6-DOF hexapod manipulator is used to provide high load capabilities and stiffness for the whole structure. The main objective of the study is to develop a suitable calibration method to improve the accuracy of the redundant serial-parallel hybrid robot. To this end, a Denavit–Hartenberg (DH) hybrid error model and a Product-of-Exponential (POE) error model are developed for error modeling of the proposed robot. Furthermore, two kinds of global optimization methods, i.e. the differential-evolution (DE) algorithm and the Markov Chain Monte Carlo (MCMC) algorithm, are employed to identify the parameter errors of the derived error model. A measurement method based on a 3-2-1 wire-based pose estimation system is proposed and implemented in a Solidworks environment to simulate the real experimental validations. Numerical simulations and Solidworks prototype-model validations are carried out on the hybrid robot to verify the effectiveness, accuracy and robustness of the calibration algorithms.

Methods of genetic diversity creation and functional display for directed evolution experiments

Protein engineering aims to improve the properties of enzymes and affinity reagents by genetic changes. Typical engineered properties are affinity, specificity, stability, expression, and solubility. Because proteins are complex biomolecules, the effects of specific genetic changes are seldom predictable. Consequently, a popular strategy in protein engineering is to create a library of genetic variants of the target molecule, and render the population in a selection process to sort the variants by the desired property. This technique, called directed evolution, is a central tool for trimming protein-based products used in a wide range of applications from laundry detergents to anti-cancer drugs. New methods are continuously needed to generate larger gene repertoires and compatible selection platforms to shorten the development timeline for new biochemicals. In the first study of this thesis, primer extension mutagenesis was revisited to establish higher quality gene variant libraries in Escherichia coli cells. In the second study, recombination was explored as a method to expand the number of screenable enzyme variants. A selection platform was developed to improve antigen binding fragment (Fab) display on filamentous phages in the third article and, in the fourth study, novel design concepts were tested by two differentially randomized recombinant antibody libraries. Finally, in the last study, the performance of the same antibody repertoire was compared in phage display selections as a genetic fusion to different phage capsid proteins and in different antibody formats, Fab vs. single chain variable fragment (ScFv), in order to find out the most suitable display platform for the library at hand. As a result of the studies, a novel gene library construction method, termed selective rolling circle amplification (sRCA), was developed. The method increases mutagenesis frequency close to 100% in the final library and the number of transformants over 100-fold compared to traditional primer extension mutagenesis. In the second study, Cre/loxP recombination was found to be an appropriate tool to resolve the DNA concatemer resulting from error-prone RCA (epRCA) mutagenesis into monomeric circular DNA units for higher efficiency transformation into E. coli. Library selections against antigens of various size in the fourth study demonstrated that diversity placed closer to the antigen binding site of antibodies supports generation of antibodies against haptens and peptides, whereas diversity at more peripheral locations is better suited for targeting proteins. The conclusion from a comparison of the display formats was that truncated capsid protein three (p3Δ) of filamentous phage was superior to the full-length p3 and protein nine (p9) in obtaining a high number of uniquely specific clones. Especially for digoxigenin, a difficult hapten target, the antibody repertoire as ScFv-p3Δ provided the clones with the highest affinity for binding. This thesis on the construction, design, and selection of gene variant libraries contributes to the practical know-how in directed evolution and contains useful information for scientists in the field to support their undertakings.