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.

THE IMPACT OF ARCHITECTURAL DESIGN ON SOFTWARE DEVELOPMENT

Tässä työssä tutkitaan ohjelmistoarkkitehtuurisuunnitteluominaisuuksien vaikutusta erään client-server –arkkitehtuuriin perustuvan mobiilipalvelusovelluksen suunnittelu- ja toteutusaikaan. Kyseinen tutkimus perustuu reaalielämän projektiin, jonka kvalitatiivinen analyysi paljasti arkkitehtuurikompponenttien välisten kytkentöjen merkittävästi vaikuttavan projektin työmäärään. Työn päätavoite oli kvantitatiivisesti tutkia yllä mainitun havainnon oikeellisuus. Tavoitteen saavuttamiseksi suunniteltiin ohjelmistoarkkitehtuurisuunnittelun mittaristo kuvaamaan kyseisen järjestelmän alijärjestelmien arkkitehtuuria ja luotiin kaksi suunniteltua mittaristoa käyttävää, työmäärää (komponentin suunnittelu-, toteutus- ja testausaikojen summa) arvioivaa mallia, joista toinen on lineaarinen ja toinen epälineaarinen. Näiden mallien kertoimet sovitettiin optimoimalla niiden arvot epälineaarista gloobaalioptimointimenetelmää, differentiaalievoluutioalgoritmia, käyttäen, niin että mallien antamat arvot vastasivat parhaiten mitattua työmäärää sekä kaikilla ominaisuuksilla eli attribuuteilla että vain osalla niistä (yksi jätettiin vuorotellen pois). Kun arkkitehtuurikompenttien väliset kytkennät jätettiin malleista pois, mitattujen ja arvoitujen työmäärien välinen ero (ilmaistuna virheenä) kasvoi eräässä tapauksessa 367 % entisestä tarkoittaen sitä, että näin muodostettu malli vastasi toteutusaikoja huonosti annetulla ainestolla. Tämä oli suurin havaitu virhe kaikkien poisjätettyjen ominaisuuksien kesken. Saadun tuloksen perusteella päätettiin, että kyseisen järjestelmän toteutusajat ovat vahvasti riippuvaisia kytkentöjen määrästä, ja näin ollen kytkentöjen määrä oli mitä todennäköisemmin kaikista tärkein työmäärään vaikuttava tekijä tutkitun järjestelmän arkkitehtuurisuunnittelussa.

Kohinan poisto spektrikuvista pehmeillä morfologisilla suodattimilla

Tämän diplomityön tavoitteena oli tutkia kohinan poistoa spektrikuvista käyttäen pehmeitä morfologisia suodattimia. Työssä painotettiin impulssimaisen kohinan suodattamista. Suodattimien toimintaa arvioitiin numeerisesti keskimääräisen itseisarvovirheen, neliövirheen sekä signaali-kohinasuhteen avulla ja visuaalisesti tarkastelemalla suodatettuja kuvia sekä niiden yksittäisiä spektritasoja. Käytettyjä suodatusmenetelmiä olivat suodatus kuvapisteittäin spektrin suunnassa, suodatus koko spektrissä sekä kuutiomenetelmä ja komponenteittainen suodatus. Suodatettavat kuvat sisälsivät joko suola ja pippuri- tai bittivirhekohinaa. Parhaimmat suodatustulokset sekä numeeristen virhekriteerien että visuaalisen tarkastelun perusteella saatiin komponenteittaisella sekä kuvapisteittäisellä menetelmällä. Työssä käytetyt menetelmät on esitetty algoritmimuodossa. Suodatinalgoritmien toteutukset ja suodatuskokeet tehtiin Matlab-ohjelmistolla.

Soft Computing Methods in Metallurgy

In metallurgic plants a high quality metal production is always required. Nowadays soft computing applications are more often used for automation of manufacturing process and quality control instead of mechanical techniques. In this thesis an overview of soft computing methods presents. As an example of soft computing application, an effective model of fuzzy expert system for the automotive quality control of steel degassing process was developed. The purpose of this work is to describe the fuzzy relations as quality hypersurfaces by varying number of linguistic variables and fuzzy sets.

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.

Dispersal and metacommunity dynamics in a soft-sediment benthic system : how well is the seafloor connected?

Connectivity depends on rates of dispersal between communities. For marine soft-sediment communities continued small-scale dispersal as post-larvae and as adults can be equally important in maintaining community composition, as initial recruitment of substrate by pelagic larvae. In this thesis post-larval dispersal strategies of benthic invertebrates, as well as mechanisms by which communities are connected were investigated. Such knowledge on dispersal is scarce, due to the difficulties in actually measuring dispersal directly in nature, and dispersal has not previously been quantified in the Baltic Sea. Different trap-types were used underwater to capture dispersing invertebrates at different sites, while in parallel measuring waves and currents. Local community composition was found to change predictably under varying rates of dispersal and physical connectivity (waves and currents). This response was, however, dependent on dispersal-related traits of taxa. Actively dispersing taxa will be relatively better at maintaining their position, as they are not as dependent on hydrodynamic conditions for dispersal and will be less prone to be passively transported by currents. Taxa also dispersed in relative proportions that were distinctly different from resident community composition and a significant proportion (40 %) of taxa were found to lack a planktonic larval life-stage. Community assembly was re-started in a large-scale manipulative field experiment over one year across several sites, which revealed how patterns of community composition (α-, β- and λ-diversity) change depending on rates of dispersal. Results also demonstrated that in response to small-scale disturbance, initial recruitment was by nearby-dominant species after which other species arrived from successively further away. At later assembly time, the number of coexisting species increased beyond what was expected purely by local niche requirements (species sorting), transferring regional differences in community composition (β-diversity) to the local scale (α-diversity, mass effect). Findings of this thesis complement more theoretical studies in metacommunity ecology by demonstrating that understanding how and when individuals disperse relative to underlying environmental heterogeneity is key to interpreting how patterns of diversity change across different spatial scales. Such information from nature is critical when predicting responses to, for example, different types of disturbances or management actions in conservation.