• Title/Summary/Keyword: Diagnostic errors

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A Cause Analysis of the Construction Incident Using Causal Loop Diagram : Safety Culture Perspective (인과지도를 활용한 건설 안전사고 원인 분석 : 안전문화 관점)

  • Choi, Yun Gil;Cho, Keun Tae
    • Journal of the Korean Society of Safety
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    • v.35 no.2
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    • pp.34-46
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    • 2020
  • Unlike research focused on existing technologies and individual errors to analyze the causes of incidents, this study approached them from an organization and culture. And this study is not a one way study but cyclical study what can track cause down using causal loop diagram methodology. Four diagnostic criteria for the negative state of the safety culture : secretive, blame, failure to learning, and incremental learning, combine literature study and expert opinion to derive 41 variables. Connecting these variable make 4 causal loop diagrams and total causal loop diagram. Case accumulation in secretive, accident report in blame, knowledge accumulation in failure to learning, near miss discovery in incremental learning are the main variables. Safety incident is the objective variable by classifying them into 4 stages in total loop, leading track as the most affect is case accumulation, and Step 4 as you can see accident report and near miss discovery are the result of tracking down the cause. This study can be used as a basis for improving the management priority and the system in incident prevention.

A water treatment case study for quantifying model performance with multilevel flow modeling

  • Nielsen, Emil K.;Bram, Mads V.;Frutiger, Jerome;Sin, Gurkan;Lind, Morten
    • Nuclear Engineering and Technology
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    • v.50 no.4
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    • pp.532-541
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    • 2018
  • Decision support systems are a key focus of research on developing control rooms to aid operators in making reliable decisions and reducing incidents caused by human errors. For this purpose, models of complex systems can be developed to diagnose causes or consequences for specific alarms. Models applied in safety systems of complex and safety-critical systems require rigorous and reliable model building and testing. Multilevel flow modeling is a qualitative and discrete method for diagnosing faults and has previously only been validated by subjective and qualitative means. To ensure reliability during operation, this work aims to synthesize a procedure to measure model performance according to diagnostic requirements. A simple procedure is proposed for validating and evaluating the concept of multilevel flow modeling. For this purpose, expert statements, dynamic process simulations, and pilot plant experiments are used for validation of simple multilevel flow modeling models of a hydrocyclone unit for oil removal from produced water.

The Performance Improvement of Lightning Arrester Leakage Current Measuring Device for GIS (GIS용 피뢰기 누설전류 측정장치 성능개선)

  • Kim, Won-Gyu;Kim, Min-Soo;Baek, Young-Sik
    • The Transactions of The Korean Institute of Electrical Engineers
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    • v.63 no.12
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    • pp.1726-1731
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    • 2014
  • This paper shows the developed new lightning arrester LCM (Leakage Current Measuring device) which is important element of GIS (Gas Insulated Switchgear) Preventive & Diagnostic system and verify its performance though strengthened test standards. The existing lightning arrester LCM was modified to solve measuring errors which happened frequently. At first, we explained the principle of measuring leakage current. Through analyzing some problems which the existing LCM have. we got some improvable items. For the performance verification of the improved LCM, we manufactured prototype LCM which is applied some improvable items such as improving LCM circuit, adding protection circuit, optimizing inner structure of LCM and changing ground design. After then we carried out the performance test. Accredited testing laboratory carried out the performance verification test according to performance test criteria and procedure of reliability test standards, IEC-60225, 61000 and 60068 etc. We confirmed the test results which correspond with the performance test criteria. Also, we confirmed the performance of the improved LCM installed & being operated at G Substation through the immunity test against the normal noise and open/close surge etc.

Design of Intelligent Servocontroller for Proportional Flow Control Solenoid Valve with Large Capacity (지능형 대용량 비례유량제어밸브 서보컨트롤러 설계)

  • Jung, G.H.
    • Transactions of The Korea Fluid Power Systems Society
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    • v.8 no.3
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    • pp.1-7
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    • 2011
  • As the technologies of electronic device have advanced these days, most of mechanical systems are designed with electronic control unit to take advantage of control parameter adaption to operating conditions and firmware flexibilities as well. On-board diagnosis, which detects the system malfunction and identifies potential source of error with its own diagnostic criteria, and fail-safe that can switch the mode of operation in view of recognized error characteristics enables easy maintenance and troubleshooting as well as system protection. This paper dealt with the development of diagnosis and fail-safe function for proportional flow control valve. All type of errors related to valve control system components are investigated and assigned to a specific hexadecimal codes. Cumulative error detection algorithm is applied in order for the sensitivity and reliability to be appropriate. Embedded simulator which runs simultaneously with system program provides the virtual error simulation environment for expeditious development of error detection algorithm. The diagnosis function was verified both with solenoid valve and embedded simulator test and it will enhance the valve control system monitoring function.

A Retrospective Review of Iatrogenic Skin and Soft Tissue Injuries

  • Lee, Tae Geun;Chung, Seum;Chung, Yoon Kyu
    • Archives of Plastic Surgery
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    • v.39 no.4
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    • pp.412-416
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    • 2012
  • Background Even though the quality of medical and surgical care has improved remarkably over time, iatrogenic injuries that require surgical treatment including injuries caused by cast and elastic bandage pressure, extravasation, and dopamine-induced ischemia still frequently occur. The goal of this study was to estimate the incidence and analyze the distribution of iatrogenic injuries referred to our department. Methods A retrospective clinical review was performed from April 2006 to November 2010. In total, 196 patients (116 females and 80 males) were referred to the plastic surgery department for the treatment of iatrogenic injuries. We analyzed the types and anatomic locations of iatrogenic complications, along with therapeutic results. Results An extravasation injury (65 cases, 37.4%) was the most common iatrogenic complication in our study sample, followed by splint-induced skin ulceration, dopamine-induced necrosis, prefabricated pneumatic walking brace-related wounds and elastic bandage-induced wounds. Among these, prefabricated pneumatic walking brace-related complication incidence increased the most during the 5-year study period. Conclusions The awareness of the very common iatrogenic complications and its causes may allow physicians to reduce their occurrence and allow for earlier detection and referral to a plastic surgeon. We believe this is the first study to analyze iatrogenic complications referred to a plastic surgery department in a hospital unit.

Curvature Based ECG Signal Compression for Effective Communication on WPAN

  • Kim, Tae-Hun;Kim, Se-Yun;Kim, Jeong-Hong;Yun, Byoung-Ju;Park, Kil-Houm
    • Journal of Communications and Networks
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    • v.14 no.1
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    • pp.21-26
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    • 2012
  • As electrocardiogram (ECG) signals are generally sampled with a frequency of over 200 Hz, a method to compress diagnostic information without losing data is required to store and transmit them efficiently on a wireless personal area network (WPAN). In this paper, an ECG signal compression method for communications onWPAN, which uses feature points based on curvature, is proposed. The feature points of P, Q, R, S, and T waves, which are critical components of the ECG signal, have large curvature values compared to other vertexes. Thus, these vertexes were extracted with the proposed method, which uses local extrema of curvatures. Furthermore, in order to minimize reconstruction errors of the ECG signal, extra vertexes were added according to the iterative vertex selectionmethod. Through the experimental results on the ECG signals from Massachusetts Institute of Technology-Beth Israel hospital arrhythmia database, it was concluded that the vertexes selected by the proposed method preserved all feature points of the ECG signals. In addition, it was more efficient than the amplitude zone time epoch coding method.

Robust Ultrasound Multigate Blood Volume Flow Estimation

  • Zhang, Yi;Li, Jinkai;Liu, Xin;Liu, Dong Chyuan
    • Journal of Information Processing Systems
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    • v.15 no.4
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    • pp.820-832
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    • 2019
  • Estimation of accurate blood volume flow in ultrasound Doppler blood flow spectrograms is extremely important for clinical diagnostic purposes. Blood volume flow measurements require the assessment of both the velocity distribution and the cross-sectional area of the vessel. Unfortunately, the existing volume flow estimation algorithms by ultrasound lack the velocity space distribution information in cross-sections of a vessel and have the problems of low accuracy and poor stability. In this paper, a new robust ultrasound volume flow estimation method based on multigate (RMG) is proposed and the multigate technology provides detail information on the local velocity distribution. In this method, an accurate double iterative flow velocity estimation algorithm (DIV) is used to estimate the mean velocity and it has been tested on in vivo data from carotid. The results from experiments indicate a mean standard deviation of less than 6% in flow velocities when estimated for a range of SNR levels. The RMG method is validated in a custom-designed experimental setup, Doppler phantom and imitation blood flow control system. In vitro experimental results show that the mean error of the RMG algorithm is 4.81%. Low errors in blood volume flow estimation make the prospect of using the RMG algorithm for real-time blood volume flow estimation possible.

Review of Application Cases of Machine Condition Monitoring Using Oil Sensors (윤활유 분석 센서를 통한 기계상태진단의 문헌적 고찰(적용사례))

  • Hong, Sung-Ho
    • Tribology and Lubricants
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    • v.36 no.6
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    • pp.307-314
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    • 2020
  • In this paper, studies on application cases of machine condition monitoring using oil sensors are reviewed. Owing to rapid industrial advancements, maintenance strategies play a crucial role in reducing the cost of downtime and improving system reliability. Consequently, machine condition monitoring plays an important role in maintaining operation stability and extending the period of usage for various machines. Machine condition monitoring through oil analysis is an effective method for assessing a machine's condition and providing early warnings regarding a machine's breakdown or failure. Among the three prevalent methods, the online analysis method is predominantly employed because this method incorporates oil sensors in real-time and has several advantages (such as prevention of human errors). Wear debris sensors are widely employed for implementing machine condition monitoring through oil sensors. Furthermore, various types of oil sensors are used in different machines and systems. Integrated oil sensors that can measure various oil attributes by incorporating a single sensor are becoming popular. By monitoring wear debris, machine condition monitoring using oil sensors is implemented for engines, automotive transmission, tanks, armored vehicles, and construction equipment. Additionally, such monitoring systems are incorporated in aircrafts such as passenger airplanes, fighter airplanes, and helicopters. Such monitoring systems are also employed in chemical plants and power plants for managing overall safety. Furthermore, widespread application of oil condition diagnosis requires the development of diagnostic programs.

Development of Head Mounted Display Interface System for Controlling Wireless Capsule Endoscope (무선 캡슐내시경 조종을 위한 머리부착형 디스플레이 인터페이스 시스템의 개발)

  • Young-Eun, Hwang;Young-Don, Son
    • Journal of Biomedical Engineering Research
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    • v.43 no.6
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    • pp.417-423
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    • 2022
  • The present study proposed a new interface system for capsule endoscopy by using head mounted display (HMD) device, which can control the orientation of the capsule endoscope with electromagnetic actuator (EMA) system. The orientation information of the HMD user was detected by the gyroscope sensor built into the device and then calculated to as an angle increment using Unity Engine compiler. The measured angle changes from the HMD were converted to the current values of the corresponding coils to be changed in the EMA system. Two experiments were designed to measure the accuracy and the intuitiveness of the HMD interface system. In the angle accuracy measurement, the capsule endoscope driven by HMD interface system showed the averaged errors of 0.68 degrees horizontally and 1.001 degrees vertically for given test angles. In the intuitiveness measurement, HMD interface system showed 1.33 times faster manipulation speed rather than the joystick interface system. In this respect, the HMD interface system for capsule endoscopy was expected to improve the overall diagnostic environment while maintaining comfort of patients and clinicians.

Missed Lung Cancers on Chest Radiograph: An Illustrative Review of Common Blind Spots on Chest Radiograph with Emphasis on Various Radiologic Presentations of Lung Cancers (놓치기 쉬운 폐암: 흉부 X선 진단의 함정에 대한 이해와 다양한 폐암 영상 소견의 중요성)

  • Goun Choi;Bo Da Nam;Jung Hwa Hwang;Ki-Up Kim;Hyun Jo Kim;Dong Won Kim
    • Journal of the Korean Society of Radiology
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    • v.81 no.2
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    • pp.351-364
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    • 2020
  • Missed lung cancers on chest radiograph (CXR) may delay the diagnosis and affect the prognosis. CXR is the primary imaging modality to evaluate the lungs and mediastinum in daily practice. The purpose of this article is to review chest radiographs for common blind spots and highlight the importance of various radiologic presentations in primary lung cancer to avoid significant diagnostic errors on CXR.