Disclosing and reporting medical errors: Cross-sectional survey of Swiss anaesthesiologists.

BACKGROUND There is limited research on anaesthesiologists' attitudes and experiences regarding medical error communication, particularly concerning disclosing errors to patients. OBJECTIVE To characterise anaesthesiologists' attitudes and experiences regarding disclosing errors to patients and reporting errors within the hospital, and to examine factors influencing their willingness to disclose or report errors. DESIGN Cross-sectional survey. SETTING Switzerland's five university hospitals' departments of anaesthesia in 2012/2013. PARTICIPANTS Two hundred and eighty-one clinically active anaesthesiologists. MAIN OUTCOME MEASURES Anaesthesiologists' attitudes and experiences regarding medical error communication. RESULTS The overall response rate of the survey was 52% (281/542). Respondents broadly endorsed disclosing harmful errors to patients (100% serious, 77% minor errors, 19% near misses), but also reported factors that might make them less likely to actually disclose such errors. Only 12% of respondents had previously received training on how to disclose errors to patients, although 93% were interested in receiving training. Overall, 97% of respondents agreed that serious errors should be reported, but willingness to report minor errors (74%) and near misses (59%) was lower. Respondents were more likely to strongly agree that serious errors should be reported if they also thought that their hospital would implement systematic changes after errors were reported [(odds ratio, 2.097 (95% confidence interval, 1.16 to 3.81)]. Significant differences in attitudes between departments regarding error disclosure and reporting were noted. CONCLUSION Willingness to disclose or report errors varied widely between hospitals. Thus, heads of department and hospital chiefs need to be aware of the importance of local culture when it comes to error communication. Error disclosure training and improving feedback on how error reports are being used to improve patient safety may also be important steps in increasing anaesthesiologists' communication of errors.

Minimum count sums for charcoalconcentration estimates in pollen slides: accuracy and potential errors

Charcoal particles in pollen slides are often abundant, and thus analysts are faced with the problem of setting the minimum counting sum as small as possible in order to save time. We analysed the reliability of charcoal-concentration estimates based on different counting sums, using simulated low-to high-count samples. Bootstrap simulations indicate that the variability of inferred charcoal concentrations increases progressively with decreasing sums. Below 200 items (i.e., the sum of charcoal particles and exotic marker grains), reconstructed fire incidence is either too high or too low. Statistical comparisons show that the means of bootstrap simulations stabilize after 200 counts. Moreover, a count of 200-300 items is sufficient to produce a charcoal-concentration estimate with less than+5% error if compared with high-count samples of 1000 items for charcoal/marker grain ratios 0.1-0.91. If, however, this ratio is extremely high or low (> 0.91 or < 0.1) and if such samples are frequent, we suggest that marker grains are reduced or added prior to new sample processing.

Mapping spectroscopic uncertainties into prospective methane retrieval errors from Sentinel-5 and its precursor

Sentinel-5 (S5) and its precursor (S5P) are future European satellite missions aiming at global monitoring of methane (CH4) column-average dry air mole fractions (XCH4). The spectrometers to be deployed onboard the satellites record spectra of sunlight backscattered from the Earth's surface and atmosphere. In particular, they exploit CH4 absorption in the shortwave infrared spectral range around 1.65 mu m (S5 only) and 2.35 mu m (both S5 and S5P) wavelength. Given an accuracy goal of better than 2% for XCH4 to be delivered on regional scales, assessment and reduction of potential sources of systematic error such as spectroscopic uncertainties is crucial. Here, we investigate how spectroscopic errors propagate into retrieval errors on the global scale. To this end, absorption spectra of a ground-based Fourier transform spectrometer (FTS) operating at very high spectral resolution serve as estimate for the quality of the spectroscopic parameters. Feeding the FTS fitting residuals as a perturbation into a global ensemble of simulated S5- and S5P-like spectra at relatively low spectral resolution, XCH4 retrieval errors exceed 0.6% in large parts of the world and show systematic correlations on regional scales, calling for improved spectroscopic parameters.

Nursing-related medication errors: A review of factors that facilitate and hinder error reporting, and recommendations for improvement

Medication errors, one of the most frequent types of medical errors, are a common cause of patient harm in hospital systems today. Nurses at the bedside are in a position to encounter many of these errors since they are there at the start of the process (ordering/prescribing) and the end of the process (administration). One of the recommendations from the IOM (Institute of Medicine) report, "To Err is Human," was for organizations to identify and learn from medical errors through event reporting systems. While many organizations have reporting systems in place, research studies report a significant amount of underreporting by nurses. A systematic review of the literature was performed to identify contributing factors related to the reporting and not reporting of medication errors by nurses at the bedside.^ Articles included in the literature review were primary or secondary studies, dated January 1, 2000 – July 2009, related to nursing medication error reporting. All 634 articles were reviewed with an algorithm developed to standardize the review process and help filter out those that did not meet the study criteria. In addition, 142 article bibliographies were reviewed to find additional studies that were not found in the original literature search.^ After reviewing the 634 articles and the additional 108 articles discovered in the bibliography review, 41 articles met the study criteria and were used in the systematic literature review results.^ Fear of punitive reactions to medication errors was a frequent barrier to error reporting. Nurses fear reactions from their leadership, peers, patients and their families, nursing boards, and the media. Anonymous reporting systems and departments/organizations with a strong safety culture in place helped to encourage the reporting of medication errors by nursing staff.^ Many of the studies included in this literature review do not allow results that can be generalized. The majority of them took place in single institutions/organizations with limited sample sizes. Stronger studies with larger sample sizes need to be performed, utilizing data collection methods that have been validated, to determine stronger correlations between safety cultures and nurse error reporting.^

Reduction of truncation errors in planar, cylindrical and partial spherical near-field antenna measurements

A method to reduce truncation errors in near-field antenna measurements is presented. The method is based on the Gerchberg-Papoulis iterative algorithm used to extrapolate band-limited functions and it is able to extend the valid region of the calculated far-field pattern up to the whole forward hemisphere. The extension of the valid region is achieved by the iterative application of a transformation between two different domains. After each transformation, a filtering process that is based on known information at each domain is applied. The first domain is the spectral domain in which the plane wave spectrum (PWS) is reliable only within a known region. The second domain is the field distribution over the antenna under test (AUT) plane in which the desired field is assumed to be concentrated on the antenna aperture. The method can be applied to any scanning geometry, but in this paper, only the planar, cylindrical, and partial spherical near-field measurements are considered. Several simulation and measurement examples are presented to verify the effectiveness of the method.

Decoding urban landscapes through the analysis of place names and imaginaries at a local scale.

Toponomastics is increasingly interested in the subjective role of place names in quotidian life. In the frame of Urban Geography, the interest in this matter is currently growing, as the recently change in modes of habitation has urged our discipline to find new ways of exploring the cities. In this context, the study of how name's significance is connected to a urban society constitutes a very interesting approach. We believe in the importance of place names as tools for decoding urban areas and societies at a local-scale. This consideration has been frequently taken into account in the analysis of exonyms, although in their case they are not exempt of political and practical implications that prevail over the tool function. The study of toponomastic processes helps us understanding how the city works, by analyzing the liaison between urban landscape, imaginaries and toponyms which is reflected in the scarcity of some names, in the biased creation of new toponyms and in the pressure exercised over every place name by tourists, residents and local government for changing, maintaining or eliminating them. Our study-case, Toledo, is one of the oldest cities in Spain, full of myths, stories and histories that can only be understood combined with processes of internal evolution of the city linked to the arrival of new residents and the more and more notorious change of its historical landscape. At a local scale, we are willing to decode the information which is contained in its toponyms about its landscape and its society.

Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting

Acknowledgements The iHARP database was funded by unrestricted grants from Mundipharma International Ltd and Research in Real-Life Ltd; these analyses were funded by an unrestricted grant from Teva Pharmaceuticals. Mundipharma and Teva played no role in study conduct or analysis and did not modify or approve the manuscript. The authors wish to direct a special appreciation to all the participants of the iHARP group who contributed data to this study and to Mundipharma, sponsors of the iHARP group. In addition, we thank Julie von Ziegenweidt for assistance with data extraction and Anna Gilchrist and Valerie L. Ashton, PhD, for editorial assistance. Elizabeth V. Hillyer, DVM, provided editorial and writing support, funded by Research in Real-Life, Ltd.

Decoding temporally encoded sensory input by cortical oscillations and thalamic phase comparators

The temporally encoded information obtained by vibrissal touch could be decoded “passively,” involving only input-driven elements, or “actively,” utilizing intrinsically driven oscillators. A previous study suggested that the trigeminal somatosensory system of rats does not obey the bottom-up order of activation predicted by passive decoding. Thus, we have tested whether this system obeys the predictions of active decoding. We have studied cortical single units in the somatosensory cortices of anesthetized rats and guinea pigs and found that about a quarter of them exhibit clear spontaneous oscillations, many of them around whisking frequencies (≈10 Hz). The frequencies of these oscillations could be controlled locally by glutamate. These oscillations could be forced to track the frequency of induced rhythmic whisker movements at a stable, frequency-dependent, phase difference. During these stimulations, the response intensities of multiunits at the thalamic recipient layers of the cortex decreased, and their latencies increased, with increasing input frequency. These observations are consistent with thalamocortical loops implementing phase-locked loops, circuits that are most efficient in decoding temporally encoded information like that obtained by active vibrissal touch. According to this model, and consistent with our results, populations of thalamic “relay” neurons function as phase “comparators” that compare cortical timing expectations with the actual input timing and represent the difference by their population output rate.

Reducing visual deficits caused by refractive errors in school and preschool children: results of a pilot school program in the Andean region of Apurimac, Peru

Background: Refractive error is defined as the inability of the eye to bring parallel rays of light into focus on the retina, resulting in nearsightedness (myopia), farsightedness (Hyperopia) or astigmatism. Uncorrected refractive error in children is associated with increased morbidity and reduced educational opportunities. Vision screening (VS) is a method for identifying children with visual impairment or eye conditions likely to lead to visual impairment. Objective: To analyze the utility of vision screening conducted by teachers and to contribute to a better estimation of the prevalence of childhood refractive errors in Apurimac, Peru. Design: A pilot vision screening program in preschool (Group I) and elementary school children (Group II) was conducted with the participation of 26 trained teachers. Children whose visual acuity was<6/9 [20/30] (Group I) and≤6/9 (Group II) in one or both eyes, measured with the Snellen Tumbling E chart at 6 m, were referred for a comprehensive eye exam. Specificity and positive predictive value to detect refractive error were calculated against clinical examination. Program assessment with participants was conducted to evaluate outcomes and procedures. Results: A total sample of 364 children aged 3–11 were screened; 45 children were examined at Centro Oftalmológico Monseñor Enrique Pelach (COMEP) Eye Hospital. Prevalence of refractive error was 6.2% (Group I) and 6.9% (Group II); specificity of teacher vision screening was 95.8% and 93.0%, while positive predictive value was 59.1% and 47.8% for each group, respectively. Aspects highlighted to improve the program included extending training, increasing parental involvement, and helping referred children to attend the hospital. Conclusion: Prevalence of refractive error in children is significant in the region. Vision screening performed by trained teachers is a valid intervention for early detection of refractive error, including screening of preschool children. Program sustainability and improvements in education and quality of life resulting from childhood vision screening require further research.

Efficient Mitigation of Data and Control Flow Errors in Microprocessors

The use of microprocessor-based systems is gaining importance in application domains where safety is a must. For this reason, there is a growing concern about the mitigation of SEU and SET effects. This paper presents a new hybrid technique aimed to protect both the data and the control-flow of embedded applications running on microprocessors. On one hand, the approach is based on software redundancy techniques for correcting errors produced in the data. On the other hand, control-flow errors can be detected by reusing the on-chip debug interface, existing in most modern microprocessors. Experimental results show an important increase in the system reliability even superior to two orders of magnitude, in terms of mitigation of both SEUs and SETs. Furthermore, the overheads incurred by our technique can be perfectly assumable in low-cost systems.

Tri-level study: modification. Task 5: an examination of driver characteristics and collision producing errors of accident and traffic violation repeaters. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Reports of cases argued and determined in the Supreme court of judicature; and in the Court for the trial of impeachments and the correction of errors in the state of New York. [1806-1823]

Imprint varies.

The Scholar armed against the errors of the time ; or, A collection of tracts on the principles and evidences of Christianity, the constitution of the Church, and the authority of civil government ... /

Edited by William Jones. Cf. Halkett & Laing.

Reports of cases, argued and determined in the Supreme Court of Errors of the State of Connecticut : prepared and published in pursuance of a statute law of the State.

"Reprint. Originally published: Hartford : G. Goodwin & Sons, 1817-[1852]