Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Iatrogenic errors and patient safety in clinical processes are an increasing concern. The quality of process information in hardcopy or electronic form can heavily influence clinical behaviour and decision making errors. Little work has been undertaken to assess the safety impact of clinical process planning documents guiding the clinical actions and decisions. This paper investigates the clinical process documents used in elective surgery and their impact on latent and active clinical errors. Eight clinicians from a large health trust underwent extensive semi- structured interviews to understand their use of clinical documents, and their perceived impact on errors and patient safety. Samples of the key types of document used were analysed. Theories of latent organisational and active errors from the literature were combined with the EDA semiotics model of behaviour and decision making to propose the EDA Error Model. This model enabled us to identify perceptual, evaluation, knowledge and action error types and approaches to reducing their causes. The EDA error model was then used to analyse sample documents and identify error sources and controls. Types of knowledge artefact structures used in the documents were identified and assessed in terms of safety impact. This approach was combined with analysis of the questionnaire findings using existing error knowledge from the literature. The results identified a number of document and knowledge artefact issues that give rise to latent and active errors and also issues concerning medical culture and teamwork together with recommendations for further work.

Growth rate and vertical propagation of the initial error in baroclinic models

The present study investigates the growth of error in baroclinic waves. It is found that stable or neutral waves are particularly sensitive to errors in the initial condition. Short stable waves are mainly sensitive to phase errors and the ultra long waves to amplitude errors. Analysis simulation experiments have indicated that the amplitudes of the very long waves become usually too small in the free atmosphere, due to the sparse and very irregular distribution of upper air observations. This also applies to the four-dimensional data assimilation experiments, since the amplitudes of the very long waves are usually underpredicted. The numerical experiments reported here show that if the very long waves have these kinds of amplitude errors in the upper troposphere or lower stratosphere the error is rapidly propagated (within a day or two) to the surface and to the lower troposphere.

Transition from an anti-phase error-correction-mode to a synchronization mode in the mutual hand tracking

Proactive motion in hand tracking and in finger bending, in which the body motion occurs prior to the reference signal, was reported by the preceding researchers when the target signals were shown to the subjects at relatively high speed or high frequencies. These phenomena indicate that the human sensory-motor system tends to choose an anticipatory mode rather than a reactive mode, when the target motion is relatively fast. The present research was undertaken to study what kind of mode appears in the sensory-motor system when two persons were asked to track the hand position of the partner with each other at various mean tracking frequency. The experimental results showed a transition from a mutual error-correction mode to a synchronization mode occurred in the same region of the tracking frequency with that of the transition from a reactive error-correction mode to a proactive anticipatory mode in the mechanical target tracking experiments. Present research indicated that synchronization of body motion occurred only when both of the pair subjects operated in a proactive anticipatory mode. We also presented mathematical models to explain the behavior of the error-correction mode and the synchronization mode.

Lunar and solar FTIR nitric acid measurements at Eureka in winter 2001/2002: comparisons with observations at Thule and Kiruna and with CMAM and SLIMCAT model calculations

For the first time, vertical column measurements of (HNO3) above the Arctic Stratospheric Ozone Observatory (AStrO) at Eureka (80N, 86W), Canada, have been made during polar night using lunar spectra recorded with a Fourier Transform Infrared (FTIR) spectrometer, from October 2001 to March 2002. AStrO is part of the primary Arctic station of the Network for the Detection of Stratospheric Change (NDSC). These measurements were compared with FTIR measurements at two other NDSC Arctic sites: Thule, Greenland (76.5N, 68.8W) and Kiruna, Sweden (67.8N, 20.4E). The measurements were also compared with two atmospheric models: the Canadian Middle Atmosphere Model (CMAM) and SLIMCAT. This is the first time that CMAM HNO3 columns have been compared with observations in the Arctic. Eureka lunar measurements are in good agreement with solar ones made with the same instrument. Eureka and Thule HNO3 columns are consistent within measurement error. Differences among HNO3 columns measured at Kiruna and those measured at Eureka and Thule can be explained on the basis of the available sunlight hours and the polar vortex location. The comparison of CMAM HNO3 columns with Eureka and Kiruna data shows good agreement, considering CMAM small inter-annual variability. The warm 2001/02 winter with almost no Polar Stratospheric Clouds (PSCs) makes the comparison of the warm climate version of CMAM with these observations a good test for CMAM under no PSC conditions. SLIMCAT captures the magnitude of HNO3 columns at Eureka, and the day-to-day variability, but generally reports higher HNO3 columns than the CMAM climatological mean columns.

Scheduling satellite-based SAR acquisition for sequential assimilation of water level observations into flood modelling

Satellite-based Synthetic Aperture Radar (SAR) has proved useful for obtaining information on flood extent, which, when intersected with a Digital Elevation Model (DEM) of the floodplain, provides water level observations that can be assimilated into a hydrodynamic model to decrease forecast uncertainty. With an increasing number of operational satellites with SAR capability, information on the relationship between satellite first visit and revisit times and forecast performance is required to optimise the operational scheduling of satellite imagery. By using an Ensemble Transform Kalman Filter (ETKF) and a synthetic analysis with the 2D hydrodynamic model LISFLOOD-FP based on a real flooding case affecting an urban area (summer 2007,Tewkesbury, Southwest UK), we evaluate the sensitivity of the forecast performance to visit parameters. We emulate a generic hydrologic-hydrodynamic modelling cascade by imposing a bias and spatiotemporal correlations to the inflow error ensemble into the hydrodynamic domain. First, in agreement with previous research, estimation and correction for this bias leads to a clear improvement in keeping the forecast on track. Second, imagery obtained early in the flood is shown to have a large influence on forecast statistics. Revisit interval is most influential for early observations. The results are promising for the future of remote sensing-based water level observations for real-time flood forecasting in complex scenarios.

Sparse probability density function estimation using the minimum integrated square error

We develop a new sparse kernel density estimator using a forward constrained regression framework, within which the nonnegative and summing-to-unity constraints of the mixing weights can easily be satisfied. Our main contribution is to derive a recursive algorithm to select significant kernels one at time based on the minimum integrated square error (MISE) criterion for both the selection of kernels and the estimation of mixing weights. The proposed approach is simple to implement and the associated computational cost is very low. Specifically, the complexity of our algorithm is in the order of the number of training data N, which is much lower than the order of N2 offered by the best existing sparse kernel density estimators. Numerical examples are employed to demonstrate that the proposed approach is effective in constructing sparse kernel density estimators with comparable accuracy to those of the classical Parzen window estimate and other existing sparse kernel density estimators.

Comparison of polar ozone loss rates simulated by one-dimensional and three-dimensional models with Match observations in recent Antarctic and Arctic winters

Simulations of ozone loss rates using a three-dimensional chemical transport model and a box model during recent Antarctic and Arctic winters are compared with experimental loss rates. The study focused on the Antarctic winter 2003, during which the first Antarctic Match campaign was organized, and on Arctic winters 1999/2000, 2002/2003. The maximum ozone loss rates retrieved by the Match technique for the winters and levels studied reached 6 ppbv/sunlit hour and both types of simulations could generally reproduce the observations at 2-sigma error bar level. In some cases, for example, for the Arctic winter 2002/2003 at 475 K level, an excellent agreement within 1-sigma standard deviation level was obtained. An overestimation was also found with the box model simulation at some isentropic levels for the Antarctic winter and the Arctic winter 1999/2000, indicating an overestimation of chlorine activation in the model. Loss rates in the Antarctic show signs of saturation in September, which have to be considered in the comparison. Sensitivity tests were performed with the box model in order to assess the impact of kinetic parameters of the ClO-Cl2O2 catalytic cycle and total bromine content on the ozone loss rate. These tests resulted in a maximum change in ozone loss rates of 1.2 ppbv/sunlit hour, generally in high solar zenith angle conditions. In some cases, a better agreement was achieved with fastest photolysis of Cl2O2 and additional source of total inorganic bromine but at the expense of overestimation of smaller ozone loss rates derived later in the winter.

A new error measure for forecasts of household-level, high resolution electrical energy consumption

As low carbon technologies become more pervasive, distribution network operators are looking to support the expected changes in the demands on the low voltage networks through the smarter control of storage devices. Accurate forecasts of demand at the single household-level, or of small aggregations of households, can improve the peak demand reduction brought about through such devices by helping to plan the appropriate charging and discharging cycles. However, before such methods can be developed, validation measures are required which can assess the accuracy and usefulness of forecasts of volatile and noisy household-level demand. In this paper we introduce a new forecast verification error measure that reduces the so called “double penalty” effect, incurred by forecasts whose features are displaced in space or time, compared to traditional point-wise metrics, such as Mean Absolute Error and p-norms in general. The measure that we propose is based on finding a restricted permutation of the original forecast that minimises the point wise error, according to a given metric. We illustrate the advantages of our error measure using half-hourly domestic household electrical energy usage data recorded by smart meters and discuss the effect of the permutation restriction.

Optimal estimation of sea surface temperature from split-window observations

Optimal estimation (OE) improves sea surface temperature (SST) estimated from satellite infrared imagery in the “split-window”, in comparison to SST retrieved using the usual multi-channel (MCSST) or non-linear (NLSST) estimators. This is demonstrated using three months of observations of the Advanced Very High Resolution Radiometer (AVHRR) on the first Meteorological Operational satellite (Metop-A), matched in time and space to drifter SSTs collected on the global telecommunications system. There are 32,175 matches. The prior for the OE is forecast atmospheric fields from the Météo-France global numerical weather prediction system (ARPEGE), the forward model is RTTOV8.7, and a reduced state vector comprising SST and total column water vapour (TCWV) is used. Operational NLSST coefficients give mean and standard deviation (SD) of the difference between satellite and drifter SSTs of 0.00 and 0.72 K. The “best possible” NLSST and MCSST coefficients, empirically regressed on the data themselves, give zero mean difference and SDs of 0.66 K and 0.73 K respectively. Significant contributions to the global SD arise from regional systematic errors (biases) of several tenths of kelvin in the NLSST. With no bias corrections to either prior fields or forward model, the SSTs retrieved by OE minus drifter SSTs have mean and SD of − 0.16 and 0.49 K respectively. The reduction in SD below the “best possible” regression results shows that OE deals with structural limitations of the NLSST and MCSST algorithms. Using simple empirical bias corrections to improve the OE, retrieved minus drifter SSTs are obtained with mean and SD of − 0.06 and 0.44 K respectively. Regional biases are greatly reduced, such that the absolute bias is less than 0.1 K in 61% of 10°-latitude by 30°-longitude cells. OE also allows a statistic of the agreement between modelled and measured brightness temperatures to be calculated. We show that this measure is more efficient than the current system of confidence levels at identifying reliable retrievals, and that the best 75% of satellite SSTs by this measure have negligible bias and retrieval error of order 0.25 K.

Error, reproducibility and sensitivity: a pipeline for data processing of Agilent oligonucleotide expression arrays

Background: Expression microarrays are increasingly used to obtain large scale transcriptomic information on a wide range of biological samples. Nevertheless, there is still much debate on the best ways to process data, to design experiments and analyse the output. Furthermore, many of the more sophisticated mathematical approaches to data analysis in the literature remain inaccessible to much of the biological research community. In this study we examine ways of extracting and analysing a large data set obtained using the Agilent long oligonucleotide transcriptomics platform, applied to a set of human macrophage and dendritic cell samples. Results: We describe and validate a series of data extraction, transformation and normalisation steps which are implemented via a new R function. Analysis of replicate normalised reference data demonstrate that intrarray variability is small (only around 2 of the mean log signal), while interarray variability from replicate array measurements has a standard deviation (SD) of around 0.5 log(2) units (6 of mean). The common practise of working with ratios of Cy5/Cy3 signal offers little further improvement in terms of reducing error. Comparison to expression data obtained using Arabidopsis samples demonstrates that the large number of genes in each sample showing a low level of transcription reflect the real complexity of the cellular transcriptome. Multidimensional scaling is used to show that the processed data identifies an underlying structure which reflect some of the key biological variables which define the data set. This structure is robust, allowing reliable comparison of samples collected over a number of years and collected by a variety of operators. Conclusions: This study outlines a robust and easily implemented pipeline for extracting, transforming normalising and visualising transcriptomic array data from Agilent expression platform. The analysis is used to obtain quantitative estimates of the SD arising from experimental (non biological) intra- and interarray variability, and for a lower threshold for determining whether an individual gene is expressed. The study provides a reliable basis for further more extensive studies of the systems biology of eukaryotic cells.

Estimating interchannel observation-error correlations for IASI radiance data in the Met Office system

The optimal utilisation of hyper-spectral satellite observations in numerical weather prediction is often inhibited by incorrectly assuming independent interchannel observation errors. However, in order to represent these observation-error covariance structures, an accurate knowledge of the true variances and correlations is needed. This structure is likely to vary with observation type and assimilation system. The work in this article presents the initial results for the estimation of IASI interchannel observation-error correlations when the data are processed in the Met Office one-dimensional (1D-Var) and four-dimensional (4D-Var) variational assimilation systems. The method used to calculate the observation errors is a post-analysis diagnostic which utilises the background and analysis departures from the two systems. The results show significant differences in the source and structure of the observation errors when processed in the two different assimilation systems, but also highlight some common features. When the observations are processed in 1D-Var, the diagnosed error variances are approximately half the size of the error variances used in the current operational system and are very close in size to the instrument noise, suggesting that this is the main source of error. The errors contain no consistent correlations, with the exception of a handful of spectrally close channels. When the observations are processed in 4D-Var, we again find that the observation errors are being overestimated operationally, but the overestimation is significantly larger for many channels. In contrast to 1D-Var, the diagnosed error variances are often larger than the instrument noise in 4D-Var. It is postulated that horizontal errors of representation, not seen in 1D-Var, are a significant contributor to the overall error here. Finally, observation errors diagnosed from 4D-Var are found to contain strong, consistent correlation structures for channels sensitive to water vapour and surface properties.

Representativity error for temperature and humidity using the Met Office high-resolution model

The observation-error covariance matrix used in data assimilation contains contributions from instrument errors, representativity errors and errors introduced by the approximated observation operator. Forward model errors arise when the observation operator does not correctly model the observations or when observations can resolve spatial scales that the model cannot. Previous work to estimate the observation-error covariance matrix for particular observing instruments has shown that it contains signifcant correlations. In particular, correlations for humidity data are more significant than those for temperature. However it is not known what proportion of these correlations can be attributed to the representativity errors. In this article we apply an existing method for calculating representativity error, previously applied to an idealised system, to NWP data. We calculate horizontal errors of representativity for temperature and humidity using data from the Met Office high-resolution UK variable resolution model. Our results show that errors of representativity are correlated and more significant for specific humidity than temperature. We also find that representativity error varies with height. This suggests that the assimilation scheme may be improved if these errors are explicitly included in a data assimilation scheme. This article is published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.

The processing of number and gender agreement in Spanish: an event related potential investigation of the effects of structural distance

Previous research suggests that the processing of agreement is affected by the distance between the agreeing elements. However, the unique contribution of structural distance (number of intervening syntactic phrases) to the processing of agreement remains an open question, since previous investigations do not tease apart structural and linear distance (number of intervening words). We used event related potentials (ERPs) to examine the extent to which structural distance impacts the processing of Spanish number and gender agreement. Violations were realized both within the phrase and across the phrase. Across both levels of structural distance, linear distance was kept constant, as was the syntactic category of the agreeing elements. Number and gender agreement violations elicited a robust P600 between 400 and 900ms, a component associated with morphosyntactic processing. No amplitude differences were observed between number and gender violations, suggesting that the two features are processed similarly at the brain level. Within-phrase agreement yielded more positive waveforms than across-phrase agreement, both for agreement violations and for grammatical sentences (no agreement by distance interaction). These effects can be interpreted as evidence that structural distance impacts the establishment of agreement overall, consistent with sentence processing models which predict that hierarchical structure impacts the processing of syntactic dependencies. However, due to the lack of an agreement by distance interaction, the possibility cannot be ruled out that these effects are driven by differences in syntactic predictability between the within-phrase and across-phrase configurations, notably the fact that the syntactic category of the critical word was more predictable in the within-phrase conditions.

Examining second language development using event-related potentials: a cross-sectional study on the processing of gender and number agreement

This cross-sectional study examines the role of L1-L2 differences and structural distance in the processing of gender and number agreement by English-speaking learners of Spanish at three different levels of proficiency. Preliminary results show that differences between the L1 and L2 impact L2 development, as sensitivity to gender agreement violations, as opposed to number agreement violations, emerges only in learners at advanced levels of proficiency. Results also show that the establishment of agreement dependencies is impacted by the structural distance between the agreeing elements for native speakers and for learners at intermediate and advanced levels of proficiency but not for low proficiency. The overall pattern of results suggests that the linguistic factors examined here impact development but do not constrain ultimate attainment; for advanced learners, results suggest that second language processing is qualitatively similar to native processing.