The aim of this thesis is to examine the contributory factors in drug errors and their reporting so as to design an enhanced reporting scheme to improve the quality of reporting in an acute hospital trust. The related research questions are: 1. What are the contributory factors in drug errors? 2. How effective is the reporting of drug errors? 3. Can an enhanced reporting scheme, predicated on the analysis of local documentary and interview data, identify the contributory factors in drug errors and improve the quality of their reporting in an acute hospital trust? The study aim and research questions reflect a growing consensus, articulated by Boaden and Walshe (2006), that patient safety research should focus on understanding the causes of adverse events and developing interventions to improve safety. Although there are concerns about the value of incident reporting (Wald & Shojania 2003, Armitage & Chapman 2007), it would appear that error reporting systems remain a high priority in advancing patient safety (Kohn et al 2000, Department of Health 2000a, National Patient Safety Agency 2004, WHO & World Alliance for Patient Safety 2004), and consequently it is the area chosen for intervention in this study. Enhancement of the existing scheme is based on a greater understanding of drug errors, their causation, and their reporting.

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Dada a importância de um sistema de prescrição, a possibilidade de ocorrências de erros no referido sistema e as conseqüências de tais erros nos resultados da terapia medicamentosa oferecida aos pacientes de uma Instituição, resolvemos desenvolver o presente trabalho. Os objetivos deste trabalho foram analisar o registro de erros relacionados à prescrição de medicamentos à pacientes internos, preparados e dispensados pela Divisão de Assistência Farmacêutica do Hospital das Clínicas da FMRP-USP, bem como contribuir para a melhoria e aprimora mento do sistema de prescrição de medicamentos e consequentemente para o uso seguro e racional dos mesmos no Hospital das Clínicas da FMRP-USP. Foi efetuado um estudo descritivo, inquérito prospectivo. Teve como população de referência prescri ções médicas e como população de estudo as prescrições médicas elabo radas pelos médicos no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. Os participantes foram as prescrições que satisfizeram os critérios de inclusão, quais sejam: prescrições médicas do Hospital das Clínicas da FMRP-USP a partir do mês de outubro de 2006, até atingir o tamanho amostral. Foi utilizada uma amostragem de conveniência até completar o número (n) de 3.456 prescrições. Depois de analisadas 3.456 prescrições concluímos que 9,05% das mesmas 17 apresentaram erros (IC entre 9% e 11%); 61,3% apresentaram erro administrativo, 20,8% erro de prescrição e 17,9% erros administrativos e erros de prescrição concomitantemente. Os erros administrativos e de prescrição foram mais freqüentes entre os médicos residentes e docentes e os erros administrativos concomitantes com os de prescrição foram entre os docentes; a versão II da prescrição eletrônica apresentou 79,8% de erros seguida da prescrição liberada pela enfermagem, que apresentou 15,4%; as clínicas que apresentaram maior quantidade de erros, por ordem decrescente, foram a Dermatologia, com 9,6%, a Urologia e Cardiologia com 8%, a Neurocirurgia com 7,0%, o Centro de Terapia Intensiva com 6,7% e a Proctologia e Gastrocirurgia, com 6,4%; o erro de leito do paciente foi o mais freqüente e cometido pelo médico residente 65,8%, seguido pelo médico contratado 25,6%; o erro de medicamento foi o erro de prescrição de maior freqüência, seguido pelo erro de dose e posteriormente pelo nome comercial; a maior freqüência de erros administrativos foi detectada na Dermatologia, seguida pela Cardiologia, Neurocirurgia e Gastrocirurgia; a maior freqüência de erros de prescrição foi observada na Ortopedia, Hematologia e Imunologia; a maior freqüência de erros de dose foi detectada na Ortopedia. / Owing to the importance of a prescription system, the possibility of error occurrences in such system, and the consequences of such errors in the results of the medicine therapy offered to the patients from an Institution, we decided to develop the current work. called . This study aims to analyze the records of errors related to the prescription of medicines to internal patients, which were prepared and issued by the Divisão de Assistência Farmacêutica do Hospital das Clínicas da FMRP-USP. It also intends to contribute to the improvement of medicine prescription systems and consequent development of sensible and safe uses of such medicines in the Hospital das Clínicas da FMRP-USP. An inquiring prospective and descriptive study was carried out, which had as referential population some medical prescriptions, and as study population the medical prescriptions elaborated by physicians in Hospital das Clínicas da FMRPUSP. The prescriptions complying with the inclusion criteria were chosen as participants; such criteria being: medical prescriptions from the Hospital das Clínicas of the FMRP-USP from October, 2006, until achieving the sample amount. A convenient sample was used until completing the number (n) of 3.456 prescriptions. After analyzing 3,456 prescriptions it was mainly concluded that: 10% of the studied prescriptions presented errors (IC between 9% and 11%); 61,3% of the prescriptions presented administrative errors, 20.8% presented prescription errors and 17.9% presented adminis trative and prescription errors concomitantly. The administrative and prescription errors occurred more frequently between resident physicians and professors, while concomitant administrative and prescription errors were more common among professors. The version II of the electronic pres cription presented 79.8% of errors, followed by prescriptions issued by the nursing which were 15,4%. The clinics presenting greater amount of errors, in decreasing order, were the Dermatology Department, with 9,6%, the Urology and Cardiology Department with 8%, the Neurosurgery Department with 7,0%, the Intensive Therapy Center, with 6,7% and the Proctology and Gastrosurgery Departments, with 6,4%. The most frequent error made by resident doctors was in reference to the patient bed, 65.8%, followed by hired doctors: 25.6%. The medicine error was the most common prescription error, followed by dosage and trade mark. The most usual administrative errors were found in the Dermatology Department, followed by the Cardiology Department, Neurosurgery and Gastrosurgery Departments; the most common prescription errors were observed in the Orthopedic, Hematology and Imunology Departments. Finally, the most frequent dosage errors were found in the Orthopedic Department.

These days, fact-checking is a fashionable term in the worlds of both politics and the media. On broadcast news, tickers run below the speeches of politicians, with claims annotated in real-time and occasionally labeled as false. In newspapers like the Washington Post and online information hubs like Politifact.com, writers invoke the term to flag reporting that aims to correct or clarify the public record. At times, "fact-checking" efforts are themselves called out for partisan bias or personal gain. The term is now practically mainstream, used in everyday conversation to indicate disbelief. ("I'm going to have to fact-check you," CNN anchor Jake Tapper said to former Baltimore mayor Stephanie Rawlings-Blake in August 2016, expressing surprise that she was the mother of a 12-year-old.) Given the proliferating parties of interest that now claim to be engaged in some sort of fact-checking endeavor--from policy think tanks to Facebook--it's no wonder that a term originally reserved for the pursuit of journalistic accuracy now suffers from muddied public understanding. This study focuses on fact-checking in the context of print magazines: the media genre that innovated a formal version of the practice nearly a century ago. Magazine fact-checking, unlike the "fact-checking" tickers of broadcast news and newspaper postmortems, focuses not on setting the record straight after the fact, but rather on getting the story right before it goes to print. If a magazine fact-checker does her work well, she'll remain invisible to the reader. And that's because the published story, after her fact-checking, will afford the reader an experience uninterrupted by questionable logic, unreliable sources, or suspect data. Magazine fact-checkers aim for this level of perfection by employing a rigorous process that goes far beyond the verification of names, dates, and numerical figures. To illustrate this process, and explain my personal investment in this craft, I share my own experience working as the head of a city magazine's fact-checking department. To gain perspective on magazine fact-checking as practiced elsewhere in the nation, I interview other fact-checkers, writers, and academics. I also draw on case studies, media history, and personal anecdotes to examine some of the fundamental questions that inform the practice. (Among them: what is a fact? When does information become true? And what are the limits of a fact-checker's pursuit of truth?) In the world of fact-checking, there are best practices in the craft, and nuances to consider. Fact-checking also wades into deeper waters: those of philosophy, ethics, and social bias. But at its core, fact-checking is quite simply an application of critical thinking skills: skills that can be honed, and used for good. At a time when the media has lost the faith of many Americans, the magazine fact-checker can play a critical role in building that trust, one scrupulously vetted story at a time.

For reliable digital communication between devices, the sources that contribute to data sampling errors must be properly modeled and understood. Clock jitter is one such error source occurring during data transfer between integrated circuits. Clock jitter is a noise source in a communication link similar to electrical noise, but is a time domain noise variable affecting many different parts of the sampling process. Presented in this dissertation, the clock jitter effect on sampling is modeled for communication systems with the degree of accuracy needed for modern high speed data communication. The models developed and presented here have been used to develop the clocking specifications and silicon budgets for industry standards such as PCI Express, USB3.0, GDDR5 Memory, and HBM Memory interfaces.

According to the National Patient Safety Foundation, more than 1.5 million Americans are affected by medication errors because of varied factors including miscommunication, bad handwriting, name confusion, poor packaging, and metric or other dosing unit errors. This project addressed medication errors and adverse drug events by developing policy and practice guidelines to support and aid the utilization of health information technology (HIT) systems in addressing medication errors and adverse drug events at a local nursing home in Cincinnati, Ohio. The National Quality Strategy Framework was used by a team of interdisciplinary stakeholders as a guide for the development of policies and practice guidelines. An interdisciplinary project team of institutional stakeholders was led by the DNP student through a review of literature to assess the effectiveness of current policies and guidelines and explore areas for improvement. New policy, practice guidelines, and educational materials were developed, along with plans for implementing and evaluating the policies in the institution. Policy and practice guidelines were shared with 4 scholars possessing expertise in health information technology to validate content of the products. Feedback was used to inform revision and preparation of final policy, practice guidelines, educational materials, and plans for implementation and evaluation. The implementation plan advocates a process that includes multiple stakeholders and institutional preparatory stages. The evaluation plan addresses multiple outcomes related to efficiency and patient safety, and proposes both intermediate and long-term evaluation based on comparisons of pre-post metrics routinely collected by the institution. Following implementation and evaluation, dissemination of results of the project may stimulate positive social change by reducing medication errors in similar health care institutions that adopt related measures.

Artificial Neural Networks have been widely probed by worldwide researchers to cope with the problems such as function approximation and data simulation. This thesis deals with Feed-forward Neural Networks (FNN's) with a new neuron activation function called Neuron-adaptive Activation Function (NAF), and Feed-forward Higher Order Neural Networks (HONN's) with this new neuron activation function. We have designed a new neural network model, the Neuron-Adaptive Neural Network (NANN), and mathematically proved that one NANN can approximate any piecewise continuous function to any desired accuracy. In the neural network literature only Zhang proved the universal approximation ability of FNN Group to any piecewise continuous function. Next, we have developed the approximation properties of Neuron Adaptive Higher Order Neural Networks (NAHONN's), a combination of HONN's and NAF, to any continuous function, functional and operator. Finally, we have created a software program called MASFinance which runs on the Solaris system for the approximation of continuous or discontinuous functions, and for the simulation of any continuous or discontinuous data (especially financial data). Our work distinguishes itself from previous work in the following ways: we use a new neuron-adaptive activation function, while the neuron activation functions in most existing work are all fixed and can't be tuned to adapt to different approximation problems; we only use on NANN to approximate any piecewise continuous function, while a neural network group must be utilised in previous research; we combine HONN's with NAF and investigate its approximation properties to any continuous function, functional, and operator; we present a new software program, MASFinance, for function approximation and data simulation. Experiments running MASFinance indicate that the proposed NANN's present several advantages over traditional neuron-fixed networks (such as greatly reduced network size, faster learning, and lessened simulation errors), and that the suggested NANN's can effectively approximate piecewise continuous functions better than neural networks groups. Experiments also indicate that NANN's are especially suitable for data simulation / Doctor of Philosophy (PhD)

The problematic areas of the teaching of Korean as a foreign language have been largely neglected in the past. Few studies combine the following three aspects: 1) an examination of learner Korean; 2) the provision of substantial linguistic and pedagogical explanations; and 3) the devising of teaching or learning strategies based on empirical evidence. By studying KFL learners and their language production, insights can be gained relating to the learning of KFL and instructors will be able to provide appropriate corrective measures. This study investigated errors produced by KFL learners, focusing primarily on high frequency orthographic, lexical and grammatical errors in written language production. The study attempts to identify key areas of difficulty in learning Korean, to investigate the possible cause of difficulties and to provide more adequate information for the teaching and learning of KFL. To this end the study uses two classes of textual data and employs both statistical and descriptive analyses. At an orthographic level the study has identified four main error categories: 1) mismatch in three series consonants, 2) mismatch in vowel sounds, 3) misuse of nasals and laterals, and 4) omission and addition of ???h???. Overall the cause of key error types correlates strongly with the differences in sound quality and sound patterns between Korean and English, with some intralingual features. At a lexical level, the study found nine types of errors including 1) semantic similarity, 2) lexical misselection and 3) overgeneralization. The findings suggest that learners have a great deal of difficulty in differentiating lexical items with similar meaning and in selecting words appropriate to particular contexts or situations. As for grammatical errors, the study identified the five most active error categories, which made up more than 80% of the total grammatical errors. An overwhelming majority of grammatical errors and case particle errors in particular were errors of substitution. Many high frequency grammatical errors had distinctive triggering factors such as particular types of verb and sentence construction. The findings of the study have several pedagogical implications. First, there are key common errors for English L1-KFL learners and these common errors need increased linguistic and pedagogical attention. Secondly, the results reinforce the need to pay more active attention to the usage of the main case particles, along with the triggering constructions causing substitutions. Thirdly, the findings suggest that different types of analysis should be done in order to facilitate a plausible description of the problematic KFL items. The study argues that despite being problematic, the items discussed in this thesis are learnable and worthy of being taught with explicit or intentional strategies and that there is a need for pedagogically effective and adequate instructional input to maximize the potential of the learner???s language development in Korean.

Background. Medication-related patient injuries (adverse drug events, ADEs) are an important problem in all hospitalised populations; however, the potential for injury is reported to be greater in children than adults. Many ADEs are due to error and therefore could be prevented. Data regarding the risk factors (or predictors) for these events in paediatric inpatients is limited. It was hypothesised that "identification of risk factors for ADEs and medication errors in the paediatric inpatient setting will inform likely prevention strategies". Aims. To determine the frequency, nature and risk factors for ADEs and potential ADEs occurring in a paediatric inpatient population; to assess the vulnerable processes in the neonatal intensive care unit (NICU) medication use process; and to provide recommendations for the targeting of likely prevention strategies. Setting. A general paediatric ward (PW), postnatal ward (PNW) and NICU of a University- affiliated urban general hospital. Design. There were two study components: the medEVENT study which involved identification of actual ADEs and potential ADEs over a twelve week period, through prospective review of medical records, medication charts and administration records along with voluntary and solicited staff report and parent interview; and the FMEA study which used a proactive risk assessment technique, Failure Mode and Effect Analysis (FMEA), to rank all potential failures in the NICU medication use process according to risk. Results. In the MedEVENT study 3160 prescription episodes were reviewed (which represented 520 admissions, 3037 patient-days) and revealed a total of 67 ADEs and 77 potential ADEs. The greatest number of events occurred in NICU with very few events in the PNW. However, paediatric surgical admissions experienced the highest rate of ADEs per 1000 patient-days (80) as compared to medical (65) then NICU admissions (19). Over half of the ADEs were deemed preventable, 38 (57%), with the �more serious� ADEs more likely to be preventable than �not serious� ADEs. The impact on hospital resources was considerable with the cost attributed to extra bed days due to ADEs to be $NZD 50,000. Dosing errors were the most common type of error, particularly when prescribing and administering medications. Antibacterial and narcotic analgesics were commonly implicated, as was the intravenous route of administration. Few events were related to unlicensed use of medications. For ADEs, the major risk factors when analysed by admission, were greater medication exposure and increasing age; by prescription, were increasing age, oral route and narcotics and antibacterial agents; for paediatric ward admission, were increasing age and increased length of stay; and for NICU admission, no major risk factors emerged. For potential ADEs, the major risk factors when analysed by admission were greater medication exposure; by prescription, were junior prescriber, intravenous route, narcotics and antibacterials; for paediatric ward admission, were junior prescriber and narcotics; and for NICU admission were antibacterials, electrolytes and umbilical venous catheter administration. Neither ADEs nor potential ADEs were associated with unlicensed use of medicines or high alert status drugs. The FMEA study identified 72 potential failures in the NICU medication use process with 193 associated causes and effects. Multiple failures were possible in the process of �prescribing medication� and in the process of �preparation of medication for administration�. The highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration. Conclusions. Analysis of the risk factors of ADEs and potential ADEs found that the most vulnerable processes were when prescribing and when preparing a medicine for administration; especially when involving narcotic and antibacterial agents and for children with greater medication exposure Strategies that selectively target these high risk areas are therefore likely to have the greatest impact on preventing drug-related injuries in hospitalised children.

Transtibial stump volume can change dramatically postoperatively and jeopardise prosthetic fitting. Differences between individuals make it hard to give general recommendations of when to fit with a definitive prosthesis. Measuring the stump volume on every patient could solve this, but most methods for volume assessments are too complicated for clinical use. The aim of this study was to evaluate accuracy and intra- and interrater precision of a method to estimate stump volume from circumferential measurements. The method approximates the stump as a number of cut cones and the tip as a sphere segment. Accuracy was evaluated theoretically on six scanned stump models in CAPOD software and manually on six stump models. Precision was evaluated by comparing measurements made by four CPOs on eight stumps. Measuring devices were a wooden rule and a metal circumference rule. The errors were estimated with intraclass correlation coefficient (ICC), where 0,85 was considered acceptable, and a clinical criterion that a volume error of ±5% was acceptable (5% corresponds to one stocking). The method was accurate on all models in theory but accurate on only four models in reality. The ICC was 0,95-1,00 for intrarater precision but only 0,76 for interrater precision. Intra- and interrater precision was unsatisfying when using clinical criteria. Variations between estimated tip heights and circumferences were causing the errors. The method needs to be developed and is not suitable for stumps with narrow ends. Using a longer rule (about 30 cm) with a set square end to assess tip heights is recommended to improve precision. Using a flexible measuring-tape (possible to disinfect) with a spring-loaded handle could improve precision of the circumferential measurements.