• Title/Summary/Keyword: Errors

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Guideline of Improvement and Evaluation of Prescribing Errors in Colorectal Chemotherapy (대장암 항암 화학요법의 처방 오류 평가 및 개선안 제시)

  • Lim, Hyun-Soo;Lim, Sung Cil
    • Korean Journal of Clinical Pharmacy
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    • v.23 no.2
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    • pp.158-166
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    • 2013
  • Background: Colorectal cancer shows a significant increase in South Korea due to westernization of diet, lack of dietary fiber, drinking and smoking, irregular defecation. There are surgery, chemotherapy, radiation therapy in treatment of colorectal cancer. There may be a medication errors in the process of chemotherapy because of its high toxicity, narrow therapeutic index and the health status of cancer patients. Consequently medication errors can cause increasing the risk of death, prolonging hospital stay and increasing the cost. Among medication errors on medication use process, prescribing errors are of particular concern due to higher risk of serious consequences. It is important for pharmacist to prevent the prescribing errors before reaching patient. Therefore we analyzed the prescriptions of colorectal cancer, classified prescribing errors, suggested guideline to reduce prescribing errors and verified the importance of pharmacist's role in prevention of medication errors activity. Methods: We collected the numbers of prescriptions of colorectal cancer(n=2,373) through anti cancer management program and EMR and analyzed the errors of prescriptions by categories from Oct 1st 2011 to Sep 30th 2012 at Chungbuk National University Hospital. We reviewed the prescriptions as follows - patients' characteristics, the result of test, previous prescriptions, characteristics of antineoplastic agents and patients' allergy, drug sensitivity, adverse events. Prescriptions are classified into inpatient and outpatient and analyzed the errors of prescriptions by categories (dosage form, dose, input, diluents, regimen, product). Results: Total prescription number of inpatient and outpatient of colorectal cancer was 1,193 and 1,180 and that of errors was 107(9%) and 22(1.9%), respectively. In case of errors of categories, the number of errors of dosage form is 69 and 8, errors of dose is 15 and 5, errors of input is 9 and 9 in inpatient and outpatient prescriptions, respectively. Errors of diluents is 8, errors of regimen is 3, errors of product is 3 in only inpatient prescriptions. In case of errors of categories by inpatient department, the number of errors of dosage form is 34 and 35, errors of dose is 7 and 8, errors of input is 6 and 3, errors of diluents is 4 and 4, errors of regimen is 2 and 1, errors of product is 2 and 1 in SG and HO, respectively. In case of outpatient department, the number of errors of dosage form is 8 in HO, errors of dose is 5 in HO, errors of input is 5 and 4 in SG and HO, respectively. Conclusions: The rate of errors of inpatient is higher than that of outpatient. Junior doctors are engaged in prescriptions of inpatient and pharmacist need to pay attention to review all prescriptions. If prescribing errors are discovered, pharmacist should contact the prescriber and correct the errors without delay. The guideline to reduce prescribing errors might be upgrading software of anti cancer management program, education for physicians as well as pharmacists and calling prescriber's attention to preventing recurrence of errors.

Prescription, Transcription and Administration Errors in Out-Patient Day Care Unit of a Regional Cancer Centre in South India

  • Mathaiyan, Jayanthi;Jain, Tanvi;Dubashi, Biswajit;Batmanabane, Gitanjali
    • Asian Pacific Journal of Cancer Prevention
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    • v.17 no.5
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    • pp.2611-2617
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    • 2016
  • Background: Medication errors are common but most often preventable events in any health care setup. Studies on medication errors involving chemotherapeutic drugs are limited. Objective: We studied three aspects of medication errors - prescription, transcription and administration errors in 500 cancer patients who received ambulatory cancer chemotherapy at a resource limited setting government hospital attached cancer centre in South India. The frequency of medication errors, their types and the possible reasons for their occurrence were analysed. Design and Methods: Cross-sectional study using direct observation and chart review in anmbulatory day care unit of a Regional Cancer Centre in South India. Prescription charts of 500 patients during a three month time period were studied and errors analysed. Transcription errors were estimated from the nurses records for these 500 patients who were prescribed anticancer medications or premedication to be administered in the day care centre, direct observations were made during drug administration and administration errors analysed. Medical oncologists prescribing anticancer medications and nurses administering medications also participated. Results: A total of 500 patient observations were made and 41.6% medication errors were detected. Among the total observed errors, 114 (54.8%) were prescription errors, 51(24.5%) were transcribing errors and 43 (20.7%) were administration errors. The majority of the prescription errors were due to missing information (45.5%) and administration errors were mainly due to errors in drug reconstitution (55.8%). There were no life threatening events during the observation period since most of the errors were either intercepted before reaching the patient or were trivial. Conclusions: A high rate of potentially harmful medication errors were intercepted at the ambulatory day care unit of our regional cancer centre. Suggestions have been made to reduce errors in the future by adoption of computerised prescriptions and periodic sensitisation of the responsible health personnel.

Evaluation Method of the Multi-axis Errors for Machining Centers (머시닝센터의 다축오차 평가 방법)

  • Hwang, Joo-Ho;Shim, Jong-Youp;Ko, Tae-Jo
    • Journal of the Korean Society for Precision Engineering
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    • v.28 no.8
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    • pp.904-914
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    • 2011
  • The volumetric errors of CNC machining centers are determined by 21 errors, including 3 linear errors, 6 straightness errors, 3 perpendicular errors, 9 angular errors and non-rigid body errors of the machine tool. It is very time consuming and hard to measure all of these errors in which laser interferometer and other parts are used directly. Hence, as many as 21 separate setups and measurements are needed for the linear, straightness, angular and perpendicular errors. In case of the 5-axis machining centers, two more rotary tables are used. It can make 35 error sources of the movement. Therefore, the measured errors of multi movements of the 5-axis tables are very complicated, even if the relative measured errors are measured. This paper describes the methods, those analyze the error sources of the machining centers. Those are based on shifted diagonal measurements method (SDM), R-test and Double ball bar. In case, the angular errors of machine are small enough comparing with others, twelve errors including three linear position errors, six straightness errors and three perpendicular errors can be calculated by using SDM. To confirm the proposed method, SDM was applied to measuring 3 axes of machine tools and compared with directly measurement of each errors. In addition, the methods for measuring relative errors of multi-axis analysis methods using R-test and Double Ball Bar are introduced in this paper.

A Study on Coding Education for Non-Computer Majors Using Programming Error List

  • Jung, Hye-Wuk
    • International Journal of Advanced Culture Technology
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    • v.9 no.1
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    • pp.203-209
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    • 2021
  • When carrying out computer programming, the process of checking and correcting errors in the source code is essential work for the completion of the program. Non-computer majors who are learning programming for the first time receive feedback from instructors to correct errors that occur when writing the source code. However, in a learning environment where the time for the learner to practice alone is long, such as an online learning environment, the learner starts to feel many difficulties in solving program errors by himself/herself. Therefore, training on how to check and correct errors after writing the program source code is necessary. In this paper, various types of errors that can occur in a Python program were described, the errors were classified into simple errors and complex errors according to the characteristics of the errors, and the distributions of errors by Python grammar category were analyzed. In addition, a coding learning process to refer error lists was designed to present a coding learning method that enables learners to solve program errors by themselves.

A Cost Sensitive Part-of-Speech Tagging: Differentiating Serious Errors from Minor Errors

  • Son, Jeong-Woo;Noh, Tae-Gil;Park, Seong-Bae
    • International Journal of Fuzzy Logic and Intelligent Systems
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    • v.12 no.1
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    • pp.6-14
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    • 2012
  • All types of part-of-speech (POS) tagging errors have been equally treated by existing taggers. However, the errors are not equally important, since some errors affect the performance of subsequent natural language processing seriously while others do not. This paper aims to minimize these serious errors while retaining the overall performance of POS tagging. Two gradient loss functions are proposed to reflect the different types of errors. They are designed to assign a larger cost for serious errors and a smaller cost for minor errors. Through a series of experiments, it is shown that the classifier trained with the proposed loss functions not only reduces serious errors but also achieves slightly higher accuracy than ordinary classifiers.

A Method for Detection and Correction of Pseudo-Semantic Errors Due to Typographical Errors (철자오류에 기인한 가의미 오류의 검출 및 교정 방법)

  • Kim, Dong-Joo
    • Journal of the Korea Society of Computer and Information
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    • v.18 no.10
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    • pp.173-182
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    • 2013
  • Typographical mistakes made in the writing process of drafts of electronic documents are more common than any other type of errors. The majority of these errors caused by mistyping are regarded as consequently still typo-errors, but a considerable number of them are developed into the grammatical errors and the semantic errors. Pseudo semantic errors among these errors due to typographical errors have more noticeable peculiarities than pure semantic errors between senses of surrounding context words within a sentence. These semantic errors can be detected and corrected by simple algorithm based on the co-occurrence frequency because of their prominent contextual discrepancy. I propose a method for detection and correction based on the co-occurrence frequency in order to detect semantic errors due to typo-errors. The co-occurrence frequency in proposed method is counted for only words with immediate dependency relation, and the cosine similarity measure is used in order to detect pseudo semantic errors. From the presented experimental results, the proposed method is expected to help improve the detecting rate of overall proofreading system by about 2~3%.

Error Analysis and Compensation for the Volumetric Errors of a Vertical Machining Center Using Hemispherical Helix Ball Bar Test (반구상의 나선형 볼바측정을 통한 수직형 머시닝 센터의 오차 해석 및 보정)

  • Yang, Seung-Han;Kim, Ki-Hoon;Park, YongKuk
    • Journal of the Korean Society for Precision Engineering
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    • v.19 no.9
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    • pp.34-40
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    • 2002
  • Machining accuracy is affected by quasi-static errors of machining center. Since machine errors have a direct influence upon both the surface finish and geometric shape of the finished workpiece, it is very important to measure the machine errors and to compensate these errors. The laser measurement method for identifying geometric errors of machine tool has the disadvantages such as high cost, long calibration time and usage of volumetric error synthesis model. Accordingly, this paper deals with analysis of the geometric errors of a machine tool using ball bar test without using complicated error synthesis model. Statistical analysis method was adopted in this paper for deriving geometric errors using hemispherical helix ball bar test. As a result of experiment, geometric errors of the vertical machining center are compensated by 88%.

A Study of Golf Swing Errors of Amateur Golfer (아마추어골퍼들의 스윙 오류에 관한 연구)

  • Lim, Jung;Jeon, Chul-Woo;Chung, Chae-Wook
    • Korean Journal of Applied Biomechanics
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    • v.16 no.2
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    • pp.165-174
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    • 2006
  • The purpose of this study was to review the relevant literature about coaching and thereupon, survey the coaching methods used for golfer lesson to reinterpret them and thereby, describe in view of kinetics the swing errors committed frequently by amateur golfers and suggest more scientific golfer coaching methods. For this purpose, kinetic elements were divided into precision and power ones and therewith, the variables affecting such elements were identified. On the other hand, swings were divided into address, take-back, back-swing, back-swing top, down-swing, impact and follow-through to determine 20 variables for each form and thereby, define their errors to determine the relations between their frequency and errors. For this study, a total of 60 amateur golfer were sampled, and their swing forms were photographed with two high-speed digital cameras, and the resultant images were analyzed to determine the errors of each form kinetically, which would be analyzed again with the program V1-5000. The results of this study can be summarized as follows; The kinetic elements could be identified as precision, power and precise power. Thus, setup and trajectory were classified into precision elements, while differences of inter-joint angles, cocking and delayed hitting. Lastly, timing and axial movement were classified into precise power elements. Three errors were identified in association with setup. The errors related with trajectory elements accounted for most (7) of the 20 errors. Three errors were determined for inter-joint angle differences, and one error was associated with cocking and delayed hitting. Lastly, one error was classified into timing error, while five errors were associated with axial movement. Finally, as a result of arranging the errors into a cross table, it was found that the errors were associated with each other between take-back and back-swing, take-back and follow-through, back-swing and back-swing top, and between back-swing and down-swing. Namely, an error would lead to other error repeatedly. So, it is more effective to identify all the errors for every form and correct them comprehensively rather than single out the errors and correct them one by one.

Analysis of Errors on Death Certificate for Trauma Related Death

  • Chang, Jun Hyuk;Kim, Sun Hyu;Lee, Hyeji;Choi, Byungho
    • Journal of Trauma and Injury
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    • v.32 no.3
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    • pp.127-135
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    • 2019
  • Purpose: This study was to investigate errors of death certificate (DC) issued for patients with trauma. Methods: A retrospective review for DC issued after death related to trauma at a training hospital trauma center was conducted. Errors on DC were classified into major and minor errors depending on their influence on the process of selecting the cause of death (COD). All errors were compared depending on the place of issue of DC, medical doctors who wrote the DC, and the number of lines filled up for COD of DC. Results: Of a total 140 DCs, average numbers of major and minor errors per DC were 0.8 and 3.7, respectively. There were a total of 2.8 errors for DCs issued at the emergency department (ED) and 5.4 errors for DCs issued beyond ED. The most common major error was more than one COD on a single line for DCs issued at the ED and incompatible casual relation between CODs for DCs issued beyond ED. The number of major errors was 0.5 for emergency physician and 0.8 for trauma surgeon and neurosurgeon. Total errors by the number of lines filled up for COD were the smallest (3.1) for two lines and the largest (6.0) for four lines. Conclusions: Numbers of total errors and major errors on DCs related to trauma only were 4 and 0.8, respectively. As more CODs were written, more errors were found.

THE PRE-SERVICE SECONDARY TEACHERS' PRESCRIPTION FOR THE MIDDLE SCHOOL STUDENTS' ERRORS IN LINEAR FUNCTIONS

  • KIM, HUIJIN;PYO, SUNG-SOO;KWON, JONGKYUM
    • East Asian mathematical journal
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    • v.31 no.4
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    • pp.609-625
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    • 2015
  • This study was subjected to 9th graders after making a conformity analysis about errors in function from a selected linear function domain learned in 8th grade, and using this we analyzed some errors learners have in the linear function domain. Learners showed the most deficiency in mastery of prerequisite facts concepts out of errors in linear functions and lack of skill in interpreting the content of the questions and technical errors occurred often as well. How the pre-service secondary school teachers prescribed these errors of linear function was analyzed from the point of problem solving strategies, accessing methods and whether or not the learner's error was used. Looking into the pre-service secondary teachers' prescription of the learners' errors in 3 fields, for the problem solving strategy a procedural strategy was used more than a conceptual strategy, and as for the accessing methods over 90% gave teacher led type explanations to the students. Also over 90% of pre-service secondary teachers did not use the learner's errors that turned up in problems.