Thesis (M.H.A.)--University of Michigan, 1960.

Thesis (M.H.A.)--University of Michigan, 1960.

No / Background: Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. Aim: The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. Methods: A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi‐disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. Results: The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems‐based. Staff felt obliged to report but rarely received feedback. Implications and conclusio: Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi‐centred evaluation.

No description available.

International Telemetering Conference Proceedings / October 25-28, 1999 / Riviera Hotel and Convention Center, Las Vegas, Nevada / This paper presents estimated aeronautical telemetry channel characteristics during bit error events. A T-39 aircraft was flown around various test corridors while transmitting a filtered 10 Mb/s pseudo-noise (PN) sequence binary phase shift keying (BPSK) signal. The received signal was down converted to 70 MHz, digitized when trigger criteria were met, and stored for later analysis. Received signal strength was also recorded. The first step in data analysis consisted of dividing the fast Fourier transform (FFT) of the recorded signal by the FFT of the expected signal. The received signal strength data was then used to correct for flat fade effects. The resulting signal is the difference (dB) between the expected signal at the receiver intermediate frequency (IF) output and the measured receiver IF output during the error event. This difference is the aeronautical telemetry channel characteristic. The characteristics of this difference signal were then matched against a 2-ray and 3-ray multipath fading model with reflected signal amplitude and path delay as the variables.

No description available.

Speech errors in normal speech provide important information about the processing mechanisms of speaking, one of the most complex cognitive, linguistic, and motor skills that human beings use for communication. Studies of speech errors form a major part of psycholinguistic research on speech production, but until recently such research has been largely based on the evidence from only a few European languages. In contrast to most speech error analyses in English, this dissertation focuses on the discussion of speech errors in Chinese, illustrating that speech errors featuring Chinese language-specific characteristics imply some processing steps that are not observed in previous speech production models. Similarities between speech errors in Chinese and English in terms of their patterns and classification suggest universality in speech production disorders in normal speech, but language-specific characteristics of the two languages suggest that English and Chinese speakers experience different processing steps in speech production, and err at different rates in different domains. For example, tonal errors in Chinese indicate that Chinese speakers undergo a special phonological process sub-step for tonal specification, this sub-step involves tone sandhi rule application, a processing task that does not concern non-tonal language speakers. A second example arises when, in the course of articulating a retrieved lexical item, the logophonographic features of the Chinese writing system provide phonological information about the lexical item through a processing step of "mental visualization". Partial visualization or incorrect phonological processing of the mentally visualized items can lead to errors of the logo-phonographic type which are not found in alphabetic languages such as English. Third, bilingual errors show that mixing of syntactic and phonological features of two different languages can occur when speech is being planned by bilingual speakers. Lastly, socio-cultural values in Chinese, such as those that involve address patterns and kinship term systems, can lead to errors that are rarely experienced by English speakers. Such different types of speech errors found in Chinese provide evidence that speech in Chinese is mediated by certain steps that have not been described in the many speech production models based on evidence derived from English errors. In general agreement with the functional-positional speech production model of Garrett (1975. 1988) and the overall language production schema of Levelt (1989. 1992), this dissertation argues for a unified speech production model that describes each of the ordered steps in the speech production process, including conceptualization, formulation, and articulation. Such a model does not overemphasize either the linguistic or psychological factors that cause speech errors. In order to precisely account for speech errors of all types in all natural languages, this model involves a set of ordered cognitive activities with psychological, linguistic, socio-cultural and contextual factors under full consideration. / Graduate

The extent to which interventions are implemented as intended is called treatment integrity (TI). Given that it is unreasonable to expect 100% TI in applied settings, a through understand of TI is essential to appropriately train teachers. This understanding must include the types of TI errors that may be committed and how these effect student learning. It is essential to study TI errors because of the real-world implications for students, including eligibility decisions for special education services, which are based upon students’ responses to inventions. It is not possible to make educational decisions on intervention effectiveness unless it is clear that evidence-based practices have been implemented accurately. If TI is low, it is impossible to determine which services and interventions a student requires. Further, measuring the fidelity with which interventions are applied allows for a more thorough and accurate understanding of which components of an intervention are effective, necessary, and feasible. A broader understanding of which TI errors are most significant, as well as measuring the necessary levels of TI, will lead to more accurate information about how to implement evidence-based practices. The purpose of this study is to gain a more nuanced understanding of TI failures in the form of errors of commission and the role commission errors have on participant responsiveness (Power, 2005). This study extends the results of DiGennaro Reed et al. (2011) by including an intermediate (80%) level of TI which may more accurately represent an attainable level of TI in applied settings. For two of four students, more errors of commission were related to lower skill acquisition. For the other two students, idiosyncratic patterns of responding emerged.

Thesis (M.Med.(Orthopaedic Surgery))--University of the Witwatersrand, Faculty of Health Sciences, 2013.

Medication errors during drug administration are an issue in the nursing profession. The errors that occur due to intravenous vein infusions pose threats to patients due to the mode of administration and the risk of occurrence. Strategies such as guardrails have been implemented to reduce the rate of such errors. Despite these guardrails, facilities record mixed results on the effectiveness of infusion pumps in reducing medication errors. The project was designed as a quantitative study to evaluate the effectiveness of guardrails in reducing medication errors at the facility. Data analysis included error reports from the facility before and after the implementation of the guardrails, as well as reports from the software used to monitor the effectiveness of the infusion pumps. Descriptive statistics was used to determine the frequency distribution, percentages, and mean, while t-tests were conducted on the two paired samples. Results showed errors reduced to 7% after the intervention, with a steady decline over the years. The p-value of 0.001 showed that there was a significant difference (α -?¤ 0.05) after the use of guardrails and prior to their usage, indicating that the intervention was effective in reducing the occurrence of medication errors. These findings can be used to promote positive social change at the facility to reduce the occurrence of medication errors during drug administration. The data will be useful to hospital administrators, nursing managers, and nursing staff to encourage compliance in the use of guardrails to help reduce medication errors.