Class of 2005 Abstract / Objectives: 1) Determine the compliance rate with 12 dispensing workflow criteria; 2) note if any dispensing errors occurred; and 3) summarize characteristics of the pharmacies studied (pharmacy staffing, dispensing workload, presence of a drive-through window, etc.). Methods: At least fifty out-window (i.e., pharmacy prescription pick up window) transactions per store were observed within 18 community retail pharmacies. Based on the historic pharmacy error incidence reports, pharmacies were categorized as being either high- or low-risk pharmacies. The compliance rates for the dispensing workflow criteria were observed between high- and low-risk pharmacies and also between different employee categories. Employee categories included pharmacists, pharmacy interns, and pharmacy technicians who were involved in the dispensing process. Results: Between August 2004 and January 2005, a total of 950 out-window transactions were observed. There were statistically significant differences seen between high- and low-risk pharmacies and between the various categories of employees. The lack of the verification of patients’ name and number of prescriptions being picked up were procedures that were more commonly associated with pharmacies reported to have high dispensing error rates. Implications: This study identified several areas where the dispensing workflow criteria were not being performed. Based on this study, the lack of the verification of patients’ name and number of prescriptions being picked up were procedures that were more commonly associated with pharmacies reported to have high dispensing error rates.

Electronic spreadsheets have made a major contribution to financial analysis and problem solving. Although professionals base many decisions on the analysis of a spreadsheet model, literature documents the data quality problems that often occur, i.e. underlying formulas and resulting numbers are frequently wrong. A growing body of evidence, gathered from students in academia as well as working professionals in business settings, indicates that these errors in spreadsheets are a pervasive problem. In addition, numerous published articles describe techniques to increase spreadsheet accuracy, but no aggregation of the topics and no model explaining this phenomenon exist. The research described here develops a theory and model of spreadsheet accuracy and then attempts to verify the propositions in a laboratory experiment. Numerous practitioner articles suggest techniques to move spreadsheets into a more structured development process, which implies an increase in spreadsheet accuracy. However, advances in our understanding of spreadsheet accuracy have been limited due to a lack of theory explaining this phenomenon. This study tests various propositions of the proposed theory. Four constructs were developed from the theory to test it. The four constructs are planning and design organization, formula complexity, testing and debugging assessment, and spreadsheet accuracy. From these four constructs three aids were designed to test the relationship between the four constructs. Each of the three aids developed was designed to increase spreadsheet accuracy by addressing a single proposition in the model. The lab experiment conducted required the participants to create a reusable spreadsheet model. The developed model and theory in this paper appear to represent the spreadsheet accuracy phenomenon. The three aids developed did increase spreadsheet data quality as measured by the number of errors in the spreadsheets. In addition, the formula complexity participants created spreadsheets that contained significantly fewer constants in formulas, and the testing and debugging participants corrected a significant number of errors after using the aid. / Ph. D.

This master’s thesis is focused on description and application of the FMEA method at the manufacturing company. The thesis is based on important steps such as introducing a knowledge database of all possible functions, failures, and countermeasures to minimize risks of a failure occurrence (detection, prevention), a failure assessment by Pareto analysis, and verification of the introduced template by a real project.

Background: Experienced clinician educators readily identify trainees with diagnostic reasoning difficulties but often lack training to diagnose and remediate errors. Taxonomies of cognitive causes of diagnostic errors can inform remediation, but clinician educators need simple tools to identify, record, report and provide feedback on these errors. A checklist may help achieve these goals. Objectives: To characterise the cognitive contributions to diagnostic errors (CCDEs), trainees make in patient encounters, with the view to develop training and remediation programmes for medical residents preparing for specialist examinations. Secondly, to determine examiners’ perceptions of a checklist in order to document and provide feedback on CCDEs to unsuccessful candidates and trainees making diagnostic errors in examinations, on ward rounds and during bedside teaching activities. Methods: Thirty examiners used a 17-item checklist to identify and record CCDEs made by medical residents failing patient encounters in a national specialist examination. A survey was used to explore examiners perceptions of the checklist to document and provide feedback on these errors. Results: Ninety-eight of 264 patient encounters were failed (37%). Ninety-four completed checklists documented 691 CCDEs (median of 7 per encounter). Cardiac (28.7%) and neurology patients (18.1%) constituted approximately half of the failed encounters. By category: data synthesis was more problematic than data gathering, faulty knowledge or data interpretation (35.2% vs. 25.8% vs. 21.9% vs. 17.1%); χ2=48.2, (p<0.0001 for all comparisons). The 'top five’ individual CCDEs were failure to elicit history and/or examination findings; poor knowledge of clinical features (illness scripts); case synthesis (putting the case together) and misinterpretation of clinical findings. History and physical examination-related errors accounted for 60% of the 'top 5’ CCDEs, Examination-related errors were more common than history-related errors (p<0.0001). The survey of the checklist was completed by all (30) examiners. Seventy-three percent finished the checklist in less than five minutes, describing it as comprehensive and easy to use. The majority (96.7%) thought the checklist could be a better way of providing structured feedback to unsuccessful candidates. Most examiners (93.3%) considered it a useful way of guiding bedside teaching for residents preparing for specialist examinations, and 76.7% thought it could improve feedback on CCDEs to unsuccessful candidates and guide remediation and training. Conclusion: A 17-item checklist identified three priority CCDEs which require focussed remediation and training in South African medical residency programmes: improving clinical skills, developing adequate illness scripts and 'putting a case together’. This does not require extensive pedagogic expertise but rather use of a simple tool to provide customised feedback, remediation and faculty support. We showed that the simple checklist used in this study helped clinician-educators/examiners without pedagogic expertise to diagnose and record CCDEs contributing to poor performance in high stakes examinations. Examiners endorsed the use of the checklist and its potential to improve feedback and training addressing CCDEs made by trainees at the bedside.

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<p>Abstract: This paper is based on a qualitative investigation concerning the effect of errors on the intelligibility of learner texts and whether there are some errors that can be considered graver than others. The investigation was based on five student texts that were collected at an upper secondary school in the Swedish province of Värmland. The texts were sent to five native speaker evaluators in Britain and the United States of America. The errors represented were categorized as followed: substance, grammar, word choice, transfer errors and other errors.The results indicate that errors concerning substance, word choice, other errors and grammar were not considered grave. Concerning the grammatical errors, there were only a small number of cases that were considered grave. Therefore, the conclusion was drawn that grammatical errors do not affect the intelligibility of any of the five texts. However, the results from the investigation show that transfer errors, i.e. when the writer has transferred characteristics from the first language to the target language, were considered affecting the intelligibility to a larger extent than errors belonging to the other categories.</p>

The objectives of this study were to examine the association between patient perceived healthcare quality and self-reported medical, medication, and laboratory errors using cross-sectional and cross-national questionnaire data from eleven countries. In this research, quality of care was measured by a multi-faceted construct, which adopted the patient's perspectives. Five separated quality of care scales were assessed: Access to Care, Continuity of care, Communication of Care, Care Coordination, and Provider's Respect for Patients' Preferences. The findings from this investigation support a number of other published studies suggesting that Coordination of Care is an important predictor of perceived patient safety. After adjusting for potentially important confounding variables, an increase in peoples' perceptions of Coordination of Care decreased the likelihood of self-reporting medical errors (OR =0.605, 95% CI: 0.569 to 0.653), medication errors (OR =0.754, 95% CI: 0.691 to 0.830), and laboratory errors (OR =0.615, 95% CI: 0.555 to 0.681). Finally, results showed that the healthcare system type governing care processes modifies the effect of Coordination of Care on self-reported medication errors.