28,888 research outputs found
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Exploring unlikely errors using video games: An example in number entry research
A common and important feature of many safety critical interactive devices is number entry. In hospitals, number entry takes the form of setting drug parameters such as doses, volumes, etc. There are several ways a number entry interface can be designed - with different consequences for error and speed. Nurses and healthcare practitioners usually have to interact with different interfaces often under pressure and stress of taking care of patients with different health conditions. Error rates in practice are low, undetected error rates are even lower and obtaining the context in which the errors occur is often incredibly difficult due to poor logging systems in many medical devices and high cost of planning and conducting empirical studies. Laboratory based studies also suffer similar limitations in that, without interventions, error rates are also too low to study. This paper explores the benefits of using a gaming context to study safety critical systems. We argue that a game paradigm provides a way that overcomes many of the problems of studying low error rates in safety critical systems and specifically for number entry in medical contexts
Technology Target Studies: Technology Solutions to Make Patient Care Safer and More Efficient
Presents findings on technologies that could enhance care delivery, including patient records and medication processes; features and functionality nurses require, including tracking, interoperability, and hand-held capability; and best practices
Using ontology in query answering systems: Scenarios, requirements and challenges
Equipped with the ultimate query answering system, computers would finally be in a position to address all our information needs in a natural way. In this paper, we describe how Language and Computing nv (L&C), a developer of ontology-based natural language understanding systems for the healthcare domain, is working towards the ultimate Question Answering (QA) System for healthcare workers. L&Câs company strategy in this area is to design in a step-by-step fashion the essential components of such a system, each component being designed to solve some one part of the total problem and at the same time reflect well-defined needs on the prat of our customers. We compare our strategy with the research roadmap proposed by the Question Answering Committee of the National Institute of Standards and Technology (NIST), paying special attention to the role of ontology
A safer place for patients: learning to improve patient safety
1 Every day over one million people are treated
successfully by National Health Service (NHS) acute,
ambulance and mental health trusts. However, healthcare
relies on a range of complex interactions of people,
skills, technologies and drugs, and sometimes things do
go wrong. For most countries, patient safety is now the
key issue in healthcare quality and risk management.
The Department of Health (the Department) estimates
that one in ten patients admitted to NHS hospitals will be
unintentionally harmed, a rate similar to other developed
countries. Around 50 per cent of these patient safety
incidentsa could have been avoided, if only lessons from
previous incidents had been learned.
2
There are numerous stakeholders with a role in
keeping patients safe in the NHS, many of whom require
trusts to report details of patient safety incidents and near
misses to them (Figure 2). However, a number of previous
National Audit Office reports have highlighted concerns
that the NHS has limited information on the extent and
impact of clinical and non-clinical incidents and trusts need
to learn from these incidents and share good practice across
the NHS more effectively (Appendix 1).
3 In 2000, the Chief Medical Officerâs report An
organisation with a memory
1
, identified that the key
barriers to reducing the number of patient safety incidents
were an organisational culture that inhibited reporting and
the lack of a cohesive national system for identifying and
sharing lessons learnt.
4 In response, the Department published Building a
safer NHS for patients3 detailing plans and a timetable
for promoting patient safety. The goal was to encourage
improvements in reporting and learning through the
development of a new mandatory national reporting
scheme for patient safety incidents and near misses. Central
to the plan was establishing the National Patient Safety
Agency to improve patient safety by reducing the risk of
harm through error. The National Patient Safety Agency was
expected to: collect and analyse information; assimilate
other safety-related information from a variety of existing
reporting systems; learn lessons and produce solutions.
5 We therefore examined whether the NHS has
been successful in improving the patient safety culture,
encouraging reporting and learning from patient safety
incidents. Key parts of our approach were a census of
267 NHS acute, ambulance and mental health trusts in
Autumn 2004, followed by a re-survey in August 2005
and an omnibus survey of patients (Appendix 2). We also
reviewed practices in other industries (Appendix 3) and
international healthcare systems (Appendix 4), and the
National Patient Safety Agencyâs progress in developing its
National Reporting and Learning System (Appendix 5) and
other related activities (Appendix 6).
6 An organisation with a memory1
was an important
milestone in the NHSâs patient safety agenda and marked
the drive to improve reporting and learning. At the
local level the vast majority of trusts have developed a
predominantly open and fair reporting culture but with
pockets of blame and scope to improve their strategies for
sharing good practice. Indeed in our re-survey we found
that local performance had continued to improve with more
trusts reporting having an open and fair reporting culture,
more trusts with open reporting systems and improvements
in perceptions of the levels of under-reporting. At the
national level, progress on developing the national reporting
system for learning has been slower than set out in the
Departmentâs strategy of 2001
3
and there is a need to
improve evaluation and sharing of lessons and solutions by
all organisations with a stake in patient safety. There is also
no clear system for monitoring that lessons are learned at the
local level. Specifically:
a The safety culture within trusts is improving, driven
largely by the Departmentâs clinical governance
initiative
4
and the development of more effective risk
management systems in response to incentives under
initiatives such as the NHS Litigation Authorityâs
Clinical Negligence Scheme for Trusts (Appendix 7).
However, trusts are still predominantly reactive in
their response to patient safety issues and parts of
some organisations still operate a blame culture.
b All trusts have established effective reporting systems
at the local level, although under-reporting remains
a problem within some groups of staff, types of
incidents and near misses. The National Patient Safety
Agency did not develop and roll out the National
Reporting and Learning System by December 2002
as originally envisaged. All trusts were linked to the
system by 31 December 2004. By August 2005, at
least 35 trusts still had not submitted any data to the
National Reporting and Learning System.
c Most trusts pointed to specific improvements
derived from lessons learnt from their local incident
reporting systems, but these are still not widely
promulgated, either within or between trusts.
The National Patient Safety Agency has provided
only limited feedback to trusts of evidence-based
solutions or actions derived from the national
reporting system. It published its first feedback report
from the Patient Safety Observatory in July 2005
Recommended from our members
Interpretive flexibility along the innovation decision process of the UK NHS Care Records Service (NCRS): Insights from a local implementation case study
Interpretive flexibility is a term used to describe the diverse perspectives on what a technology is and can or can not do during the process of technological development. In this article, we look at how interpretive flexibility manifests through the diverse perceptions of stakeholders involved in the diffusion and adoption of the NHS Care Records Service (NCRS). Our analysis shows that while the policy makers acting upon the application of details related to the implementation of the system, the potential users are far behind the innovation decision process, namely at the knowledge or persuasion stages. We use data from a local heath authority from a county close to London. The research explores, compares, and evaluates contrasting views on the systems implementation at the local as well as national level. We believe that our analysis is useful for NCRS implementation strategies, in particular, and technology diffusion in large organisations, in general
Visualizing Magnitude: Graphical Number Representations Help Users Detect Large Number Entry Errors
Nurses frequently have to program infusion pumps to deliver a prescribed quantity of drug over time. Occasional errors are made in the performance of this routine number entry task, resulting in patients receiving the incorrect dose of a drug. While many of these number entry errors are inconsequential, others are not; infusing 100 ml of a drug instead of 10 ml can be fatal. This paper investigates whether a supplementary graphical number representation, depicting the magnitude of a number, can help people detect number entry errors. An experiment was conducted in which 48 participants had to enter numbers from a âprescription sheetâ to a computer interface using a keyboard. The graphical representation was supplementary and was shown both on the âprescription sheetâ and the device interface. Results show that while overall more errors were made when the graphical representation was visible, the graphical representation helped participants to detect larger number entry errors (i.e., those that were out by at least an order of magnitude). This work suggests that a graphical number entry system that visualizes magnitude of number can help people detect serious number entry errors
The Importance Of Community: Investing In Effective Community-Based Crime Prevention Strategies
After more than a year of listening to our community, researching evidence-based practices, and evaluating our own efforts, 'The Importance of Community' inaugural report unequivocally asserts that our greatest potential of reducing homicides and incarceration as a result of committing a crime is deeply rooted in collective community action and targeted interventions aimed at serving narrowly defined populations. In this report, The Indianapolis Foundation will summarize years of community-based recommendations and provides a specific community investment plan based on multiple community convenings, crime prevention related reports, and listening to our community
A computer supported memory aid for copying prescription parameters into medical equipment based on linguistic phrases
Manually operated medical equipment, including drug
infusion pumps, are often subject to input errors. Human
operators copy data from a prescription into the relevant form
field on the equipment panels. This process is error prone and
time consuming. A computer supported memory aid is proposed
where the user remembers phrases instead of value sequences.
The proposed strategy speeds up the task of setting up medical
equipment while reducing the chances of human errors
Web-based haptic applications for blind people to create virtual graphs
Haptic technology has great potentials in many applications. This paper introduces our work on delivery haptic information via the Web. A multimodal tool has been developed to allow blind people to create virtual graphs independently. Multimodal interactions in the process of graph creation and exploration are provided by using a low-cost haptic device, the Logitech WingMan Force Feedback Mouse, and Web audio. The Web-based tool also provides blind people with the convenience of receiving information at home. In this paper, we present the development of the tool and evaluation results. Discussions on the issues related to the design of similar Web-based haptic applications are also given
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