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Managers of growing businesses face a number of challenges in controlling business activities. This situation gives rise to an increased risk of error and fraud in enterprises. It is imperative that measures be taken to detect and prevent fraud, regardless of the size of the enterprise. In light of the recent financial events and new legal regulations that have come into force, it is becoming increasingly evident that traditional audit methods are being replaced by digital audits. One of the important methods in preventing and detecting fraud is continuous auditing. The objective of this study is to ascertain the scientific orientation of research on continuous auditing in Turkey between 2011 and 2024. In this direction, literature review and content analysis of the studies on continuous auditing accessed through Google Scholar, TR Index, Dergipark, EKUAL Discovery and Web of Science (WOS) databases were conducted. According to the results of the literature review, prominent topics include the relationship between continuous auditing and internal auditing, the fraud prevention effectiveness of continuous auditing, the relationship between continuous auditing and independent auditing, and the future of continuous auditing. It is observed that the most research on this subject was conducted between 2018 and 2020. These studies support the need for a conceptual framework to develop a more effective and modern continuous auditing model. Increasing the number of studies conducted in the field of continuous auditing in Turkey is considered to be highly beneficial for sectors as the amount of big data continues to grow. [ABSTRACT FROM AUTHOR]

Das Projekt „Sichere Gabe von Chemotherapeutika“ am Universitätsklinikum Essen zielt darauf ab, die Sicherheit der Chemotherapiebehandlung durch aktive Einbeziehung der Patient:innen zu verbessern. Hierzu wurden Patient:innen zu ihren Erfahrungen und Wünschen im Hinblick auf die Einbeziehung in die Chemotherapiebehandlung befragt. Dabei wurden die häufigsten Fehler bei der Gabe von Chemotherapeutika identifiziert. Es wurde ein patientenadaptierter Therapieplan mit den wichtigsten Informationen zur Chemotherapie entwickelt. Aus dem Projekt konnte gelernt werden, dass die Einbeziehung der Patient:innen in die Chemotherapiebehandlung ein wichtiger Ansatz zur Verbesserung der Patientensicherheit ist, weiter zeigt sich, wie dies erfolgreich umgesetzt werden kann. Weitere Forschung ist notwendig, um die besten Methoden zur Einbeziehung von Patient:innen in die Behandlung zu identifizieren.

Abstract Background Electronic medical record (EMR) systems provide timely access to clinical information and have been shown to improve medication safety. However, EMRs can also create opportunities for error, including system-related errors or errors that were unlikely or not possible with the use of paper medication charts. This study aimed to determine the detection and mitigation strategies adopted by a health district in Australia to target system-related errors and to explore stakeholder views on strategies needed to curb future system-related errors from emerging. Methods A qualitative descriptive study design was used comprising semi-structured interviews. Data were collected from three hospitals within a health district in Sydney, Australia, between September 2020 and May 2021. Interviews were conducted with EMR users and other key stakeholders (e.g. clinical informatics team members). Participants were asked to reflect on how system-related errors changed over time, and to describe approaches taken by their organisation to detect and mitigate these errors. Thematic analysis was conducted iteratively using a general inductive approach, where codes were assigned as themes emerged from the data. Results Interviews were conducted with 25 stakeholders. Participants reported that most system-related errors were detected by front-line clinicians. Following error detection, clinicians either reported system-related errors directly to the clinical informatics team or submitted reports to the incident information management system. System-related errors were also reported to be detected via reports run within the EMR, or during organisational processes such as incident investigations or system enhancement projects. EMR redesign was the main approach described by participants for mitigating system-related errors, however other strategies, like regular user education and minimising the use of hybrid systems, were also reported. Conclusions Initial detection of system-related errors relies heavily on front-line clinicians, however other organisational strategies that are proactive and layered can improve the systemic detection, investigation, and management of errors. Together with EMR design changes, complementary error mitigation strategies, including targeted staff education, can support safe EMR use and development.

Background: Electronic medical record (EMR) systems provide timely access to clinical information and have been shown to improve medication safety. However, EMRs can also create opportunities for error, including system-related errors or errors that were unlikely or not possible with the use of paper medication charts. This study aimed to determine the detection and mitigation strategies adopted by a health district in Australia to target system-related errors and to explore stakeholder views on strategies needed to curb future system-related errors from emerging. Methods: A qualitative descriptive study design was used comprising semi-structured interviews. Data were collected from three hospitals within a health district in Sydney, Australia, between September 2020 and May 2021. Interviews were conducted with EMR users and other key stakeholders (e.g. clinical informatics team members). Participants were asked to reflect on how system-related errors changed over time, and to describe approaches taken by their organisation to detect and mitigate these errors. Thematic analysis was conducted iteratively using a general inductive approach, where codes were assigned as themes emerged from the data. Results: Interviews were conducted with 25 stakeholders. Participants reported that most system-related errors were detected by front-line clinicians. Following error detection, clinicians either reported system-related errors directly to the clinical informatics team or submitted reports to the incident information management system. System-related errors were also reported to be detected via reports run within the EMR, or during organisational processes such as incident investigations or system enhancement projects. EMR redesign was the main approach described by participants for mitigating system-related errors, however other strategies, like regular user education and minimising the use of hybrid systems, were also reported. Conclusions: Initial detection of system-related errors relies heavily on front-line clinicians, however other organisational strategies that are proactive and layered can improve the systemic detection, investigation, and management of errors. Together with EMR design changes, complementary error mitigation strategies, including targeted staff education, can support safe EMR use and development. [ABSTRACT FROM AUTHOR]

Effective coordination among health care professionals is crucial to achieving optimal outcomes. In the OR, even minor errors can have catastrophic consequences. To mitigate the risk of error, health care professionals have adopted a briefing culture like that used in the aviation industry. Briefings are essential to ensure that everyone involved in a procedure knows the plan and potential risks and is prepared to perform their duties safely and effectively. The fundamental human sense involved in briefings is auditory perception; although important, hearing alone does not equate to focused attention. To enhance the efficacy of briefings, engaging the use of a second sense by adding a visual checklist may increase attentiveness and the chances of early error detection and prevention. Using a projection device may enhance all team members' engagement and participation during the briefing or time‐out process and can be an effective tool for improving communication and reducing errors. [ABSTRACT FROM AUTHOR]

Background: Simulated error training is a method to practice error detection in situations where the occurrence of error is low. Such is the case for the physics plan and chart review where a physicist may check several plans before encountering a significant problem. By simulating potentially hazardous errors, physicists can become familiar with how they manifest and learn from mistakes made during a simulated plan review. Purpose: The purpose of this project was to develop a series of training datasets that allows medical physicists and trainees to practice plan and chart reviews in a way that is familiar and accessible, and to provide exposure to the various failure modes (FMs) encountered in clinical scenarios. Methods: A series of training datasets have been developed that include a variety of embedded errors based on the risk‐assessment performed by American Association of Physicists in Medicine (AAPM) Task Group 275 for the physics plan and chart review. The training datasets comprise documentation, screen shots, and digital content derived from common treatment planning and radiation oncology information systems and are available via the Cloud‐based platform ProKnow. Results: Overall, 20 datasets have been created incorporating various software systems (Mosaiq, ARIA, Eclipse, RayStation, Pinnacle) and delivery techniques. A total of 110 errors representing 50 different FMs were embedded with the 20 datasets. The project was piloted at the 2021 AAPM Annual Meeting in a workshop where participants had the opportunity to review cases and answer survey questions related to errors they detected and their perception of the project's efficacy. In general, attendees detected higher‐priority FMs at a higher rate, though no correlation was found between detection rate and the detectability of the FMs. Familiarity with a given system appeared to play a role in detecting errors, specifically when related to missing information at different locations within a given software system. Overall, 96% of respondents either agreed or strongly agreed that the ProKnow portal and training datasets were effective as a training tool, and 75% of respondents agreed or strongly agreed that they planned to use the tool at their local institution. Conclusions: The datasets and digital platform provide a standardized and accessible tool for training, performance assessment, and continuing education regarding the physics plan and chart review. Work is ongoing to expand the project to include more modalities, radiation oncology treatment planning and information systems, and FMs based on emerging techniques such as auto‐contouring and auto‐planning. [ABSTRACT FROM AUTHOR]

Knowledge work or non-routine work such as the development of smartphone apps or software for controlling modern aircraft is per se prone to errors. Concrete examples from everyday life show that such errors can mean incalculable damage to life and limb and must therefore be avoided. Mutual explanation and mutual understanding of facts, suggestions, ideas, concepts are error-relevant building blocks of knowledge work in teams. The better these special forms of teaching (explaining) and learning (understanding) succeed, the greater the chances of avoiding errors appear. Accordingly, it is suggested to view knowledge work from a learning and teaching perspective and to support it with instruments from didactics. This learning-teaching orientation and its contribution to error reduction are described, explained by one concrete example, and discussed in summary. [ABSTRACT FROM AUTHOR]

Objectives: To study the pharmacists’ contributions to medication error (ME) prevention in Saudi Arabia Methods: To locate research that met the inclusion criteria, a thorough computerized search of relevant databases was carried out. A comprehensive search was carried out on PubMed, SCOPUS, Science Direct, Cochrane Library, and Web of Science to locate relevant material. Results: Our data included seven trials with 83,705 MEs. MEs reported by pharmacists varied across studies, with rates ranging from approximately 54% to over 96%. The majority of errors reported were related to prescribing and dispensing, with pharmacists consistently identifying more errors compared to other healthcare professionals. Key challenges included poor communication between pharmacists and physicians, which contributed to the occurrence of MEs. The review also highlighted the lack of reporting by other healthcare providers, underscoring the need for a more collaborative approach to reducing MEs. Conclusion: Pharmacists play a critical role in improving medication safety, but there are gaps in research and practice. While they have proven to be effective in reducing errors, more work is needed to encourage other healthcare professionals to take a more active role in reporting and preventing these errors. Future studies should focus on prospective designs, improving inter-professional communication, and exploring the role of pharmacists in non-hospital settings.

As the intensity of communication increases, the number of language mistakes/errors increases. Nowadays, the acquisition and use of a foreign language often takes place in parallel, and language mistakes/errors are a natural part of this process but this does not mean that they must be tolerated. The study is based on the results of a sociolinguistic survey obtained in 2018 and 2019. 253 students of four Universities and specialties, as well as different study levels from Liepāja, Ventspils and Rīga participated in the survey anonymously. Most of the respondents indicated that Latvian was their mother tongue; for a small number of participants, it was a second language or a foreign language. The surveyed students also differed in the type and number of foreign languages acquired. The present paper is the second part of a wider study (see the results of the first stage of the research by Laiveniece and Lauze, 2020). The aim of this paper is to characterize students’ linguistic attitude towards language errors in learning and using a foreign language: how to evaluate errors, whether errors are generally permissible, what affects them, and how to eliminate them. In the course of the research, an assumption emerged: the more foreign languages are learned, the more tolerant the linguistic attitude is towards mistakes/errors that are made when speaking a foreign language. However, the analysis of the questionnaire findings did not confirm this. Most of the respondents attributed errors to the language learning process. Whether or not errors were made when speaking a foreign language was determined by the situation and purpose of the communication, as well as the level of language acquisition.

We study errors in organizations to understand and ideally prevent them from reoccurring. In this study we examine mistakes made as an oil company adopted new technology to access untapped reserves. We find that a pre-existing error management culture (EMC) dominated in the organization while error prevention measures were deficient. This is surprising given the complexity of the business and the importance of safety. We show that a balance between error prevention and error management is difficult to achieve owing to the contradictory nature of these approaches. While the extant organizational error literature identifies the complementary aspect of error prevention and error management it does not consider their interrelatedness-how one affects the other. We find that the dominating error management culture at Suncor Energy contributed to error prevention processes that were misapplied, informal or absent. This highlights the need for deliberate examination of error approaches especially as the business context shifts. [ABSTRACT FROM AUTHOR]

Although nowadays unmanned systems have become widespread with Industry 4.0, it is seen that there are still many labor-intensive production systems. At this point, poka-yoke emerges as a lean production tool that prevents the labor-intensive workforce from making mistakes and ensures that mistakes are prevented before they occur. In this study, a human-induced error in printing the date on the can, one of the last stages of production in a tomato paste canning facility, was tried to be prevented by the poka-yoke study. The performed analysis has determined that the workplace layout and the method of placing the products on the belt are the main reasons for the error. The errors by the developed poka-yoke system have been considerably reduced. In addition, with the reorganization of the workplace, the operator's posture and the station position that could cause errors were fixed, and an employee was enabled to work more ergonomically. As a result of the study, some time and cost advantages were achieved. [ABSTRACT FROM AUTHOR]

Background: Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery. Methods: In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40 s prior and 10 s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses. Results: Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p =.008) and motor uncertainty (p =.034) was detected 17 s prior to errors, but not prior to good surgical performance. Conclusions: These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions—before errors occur and cause patient harm. [ABSTRACT FROM AUTHOR]

We study errors in organizations to understand and ideally prevent them from reoccurring. In this study we examine mistakes made as an oil company adopted new technology to access untapped reserves. We find that a pre-existing error management culture (EMC) dominated in the organization while error prevention measures were deficient. This is surprising given the complexity of the business and the importance of safety. We show that a balance between error prevention and error management is difficult to achieve owing to the contradictory nature of these approaches. While the extant organizational error literature identifies the complementary aspect of error prevention and error management it does not consider their interrelatedness–how one affects the other. We find that the dominating error management culture at Suncor Energy contributed to error prevention processes that were misapplied, informal or absent. This highlights the need for deliberate examination of error approaches especially as the business context shifts.

Background: Medication errors may occur during chemotherapy and can have fatal consequences. Healthcare Failure Mode and Effects Analysis (FMEA) is a method used to detect potential risks and prevent them.Objective: Aim of this study was to evaluate the medication process of intravenous tumor therapy in order to guarantee a high standard of patient safety.Methods: The main part of the study was performed at the University Hospital of Bonn, Germany. After assembling a multidisciplinary team, the individual steps of prescription, compounding, transport, and administration of chemotherapy were mapped in a flow diagram. The possible failures were identified and analyzed by calculating the risk priority numbers (RPNs). Finally, corrective actions were developed and after hypothetical implementation re-analyzed to measure their effects on the process. Subsequently, a shortened FMEA based on the catalogue failure modes developed in Bonn was carried out at the University Hospital of Cologne in order to evaluate its transferability to another hospital.Results: A total of 52 potential failure modes was identified in Bonn. Relating to the RPNs the most critically steps in the process were associated with the prescription, namely, incorrect information about individual parameters of the patient; non-standardized chemotherapy protocols; and problems related to supportive therapy. A significant risk reduction for most of the failure modes was assessed by implementing suitable corrective actions. The shortened FMEA in Cologne led to a different ranking of failure modes.Conclusion: The implementation of this analysis has not only identified various safety gaps, but also shows how patient safety during chemotherapy can be enhanced. Moreover, it has sensitized the practitioners to failure modes potentially occurring in their work routine. [ABSTRACT FROM AUTHOR]

Background: One factor that could cause medical errors is confusing medicines with similar names. A previous study showed that nurses who have knowledge about drugs faced difficulty in discriminating a drug name from similar pseudo-drug names. To avoid such errors, finger-pointing and calling (FPC) has been recommended in Japan. Objectives: The present study had two aims. The first was to determine whether such difficulty was due to top-down processing, rather than bottom-up processing, being applied even for pseudo-names. The other was to investigate whether FPC affected error prevention for similar drug names. Method: In two experiments, nurses and non–health care professionals performed a choice reaction time task for drug names and common words, with or without FPC. Error rate and reaction time were analyzed. Results: When drug names were used, nurses showed difficulty discriminating target names from distractors. Furthermore, the error prevention effect of FPC was marginally significant for drug names. However, nurses showed no significant differences when similar drug names were used. There was no significant difference regarding the error rate for words. Conclusions: Nurses' knowledge of drug names activates top-down processing. As a result, the processing of drug names was not as accurate and quick as that for words for nurses, which caused difficulty in discriminating similar names. FPC may be applicable to reduce confusion errors, possibly by leading individuals to process drug names using bottom-up processing. Application: The present study advances current knowledge about error tendencies with similar drug names and the effects of FPC on error prevention. [ABSTRACT FROM AUTHOR]

Rework has been and continues to be a problem during the construction of transport mega-projects. This article examines the error culture of an alliance that forms part of a transport mega-project to determine its effectiveness in mitigating rework. Our article reveals that an error management culture positively correlates with reducing rework and holds a divergent relationship with an error aversion culture. We further show a negative association between an error aversion culture and the ability to reduce rework. It is suggested that more can be done to reduce errors and rework despite the prevalence of a strong error management culture in practice. We thus call for an explicit focus on reducing negative error consequences and developing strategies to handle errors. The article argues that providing a psychologically safe work environment, understanding and focusing on what goes right, and coaching to ensure that learning is transferred from an individual to an organizational level can reduce rework. Our study is the first attempt to examine the homogeneity of error culture (i.e., how errors and their consequences are dealt with) in an alliance mega-project setting. In addition, it provides a new line of exploration to address the issue of rework.

The research we present in this paper addresses the following question: What type of error culture does the rank-and-file workforce experience during construction, and does it help mitigate rework? We undertake an exploratory case study of an Alliance, which forms part of a transport mega-project. An error culture questionnaire is administered to the Alliance's subcontractors' workforce across four projects. We find that an error management culture positively correlates with reductions in rework and holds a divergent relationship with an error aversion culture. We further reveal a negative association between an error aversion culture and the ability to reduce rework. Consequently, we question the contemporary wisdom that assumes that error prevention should be combined with error management to create an adaptive culture, aiming to minimise the negative and maximise positive error consequences. We finally discuss the study's limitations and implications for future research examining error culture in construction projects.

To rapidly prognosticate and generate hypotheses on pathogenesis, leukocyte multi-cellularity was evaluated in SARS-CoV-2 infected patients treated in India or the United States (152 individuals, 384 temporal observations). Within hospital (<90-day) death or discharge were retrospectively predicted based on the admission complete blood cell counts (CBC). Two methods were applied: (i) a "reductionist" one, which analyzes each cell type separately, and (ii) a "non-reductionist" method, which estimates multi-cellularity. The second approach uses a proprietary software package that detects distinct data patterns generated by complex and hypothetical indicators and reveals each data pattern's immunological content and associated outcome(s). In the Indian population, the analysis of isolated cell types did not separate survivors from non-survivors. In contrast, multi-cellular data patterns differentiated six groups of patients, including, in two groups, 95.5% of all survivors. Some data structures revealed one data point-wide line of observations, which informed at a personalized level and identified 97.8% of all non-survivors. Discovery was also fostered: some non-survivors were characterized by low monocyte/lymphocyte ratio levels. When both populations were analyzed with the non-reductionist method, they displayed results that suggested survivors and non-survivors differed immunologically as early as hospitalization day 1. [ABSTRACT FROM AUTHOR]

Vision picking empowers users with access to real-time digital order information, while freeing them from handheld radio frequency devices. The smart glasses, as an example of vision picking enabler, provide visual and voice cues to guide order pickers. The glasses mostly also have installed navigation features that can sense the order picker’s position in the warehouse. This paper explores picking errors in vision systems with literature review and experimental work in laboratory environment. The results show the effectiveness of applying vision picking systems for the purposes of active error prevention, when they are compared to established methods, such as paper-picking and using cart mounted displays. A serious competitor to vision picking systems are pick-to-light systems.

To rapidly prognosticate and generate hypotheses on pathogenesis, leukocyte multi-cellularity was evaluated in SARS-CoV-2 infected patients treated in India or the United States (152 individuals, 384 temporal observations). Within hospital (

Modern assembly systems adapt to the requirements of customised and short-lived products. As assembly tasks become increasingly complex and change rapidly, the cognitive load on employees increases. This leads to the use of assistance systems for manual assembly to detect and avoid human errors and thus ensure consistent product quality. Most of these systems promise to improve the production environment but have hardly been studied quantitatively so far. Recent advances in deep learning-based computer vision have also not yet been fully exploited. This study aims to provide architectural, and implementational details of a state-of-the-art assembly assistance system based on an object detection model. The proposed architecture is intended to be representative of modern assistance systems. The error prevention potential is determined in a case study in which test subjects manually assemble a complex explosion-proof tubular lamp. The results show 51 % fewer assembly errors compared to a control group without assistance. Three of the four considered types of error classes have been reduced by at least 42 %. In particular, errors by omission are most likely to be prevented by the system. The reduction in the error rate is observed over the entire period of 30 consecutive product assemblies, comparing assisted and unassisted assembly. Furthermore, the recorded assembly data are found to be valuable regarding traceability and production improvement processes. [ABSTRACT FROM AUTHOR]

• 21% of all relevant events found in three different incident learning databases were likely to be preventable with SGRT. • The most preventable events with SGRT were incorrect isocenter and incorrect immobilization. • Events with the potential to be mitigated by SGRT were generally of higher severity. • SGRT was found to also introduce new failure modes. • Improved vendor integration could further enhance patient safety. Emerging data indicates SGRT could improve safety and quality by preventing errors in its capacity as an independent system in the treatment room. The aim of this work is to investigate the utility of SGRT in the context of safety and quality. Three incident learning systems (ILS) were reviewed to categorize and quantify errors that could have been prevented with SGRT: SAFRON (International Atomic Energy Agency), UW-ILS (University of Washington) and AvIC (Skåne University Hospital). A total of 849/9737 events occurred during the pre-treatment review/verification and treatment stages. Of these, 179 (21%) events were predicted to have been preventable with SGRT. The most common preventable events were wrong isocentre (43%) and incorrect accessories (34%), which appeared at comparable rates among SAFRON and UW-ILS. The proportion of events due to wrong accessories was much smaller in the AvIC ILS, which may be attributable to the mandatory use of SGRT in Sweden. Several case scenarios are presented to demonstrate that SGRT operates as a valuable complement to other quality-improvement tools routinely used in radiotherapy. Cases are noted in which SGRT itself caused incidents. These were mostly related to workflow issues and were of low severity. Severity data indicated that events with the potential to be mitigated by SGRT were of higher severity for all categories except wrong accessories. Improved vendor integration of SGRT systems within the overall workflow could further enhance its clinical utility. SGRT is a valuable tool with the potential to increase patient safety and treatment quality in radiotherapy. [ABSTRACT FROM AUTHOR]

Background: Checklists have been shown to reduce morbidity and mortality in medicine by improving documentation and reducing errors. In the modern era of care, where patients are the centre of decision-making, this study examines patient perception of care and error prevention with the use of ward round checklist. Methods: We conducted a prospective stepped-wedge cluster randomized controlled checklist intervention study using a standardized questionnaire to investigate patients’ perception of ward rounds before and after implementation of a ward round checklist. Results: A total of 124 patients completed the questionnaire. The overall percentage of items endorsed increased significantly by 5.1% from 64.8% to 70.0% (P = 0.014). Statistically significant improvements were seen in patients knowing their diagnosis (P = 0.027), the day’s plan (P = 0.038), observing a medication chart (P < 0.001) and observation chart review (P = 0.008). Conclusion: Our study indicates that the use of a ward round checklist leads to patient-perceived improvements in aspects of quality of care. [ABSTRACT FROM AUTHOR]

Background: Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety. Objective: To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role. Materials and methods: All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities. Results: In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%). Conclusion: Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm. [ABSTRACT FROM AUTHOR]

Purpose: Traditionally, the treatment couch coordinates (TCCs) for patients undergoing radiotherapy can only be determined at the time of treatment, placing pressure on the treating therapists and leaving several pathways for errors such as wrong‐site treatment or wrong treatment table shift from a reference point. The purpose of this work is to propose an accurate, robust, and streamlined system that calculates TCC in advance. Methods: The proposed system combines the advantages of two different calculation methods that use an indexed immobilization device. The first method uses an array of reference ball bearings (BBs) embedded in the CT scanner's couch‐top. To obtain the patient‐specific TCC, the spatial offset of the treatment planning isocenter from the reference BB is used. The second method performs a calculation using the one‐to‐one mapping relationship between the CT scanner's DICOM (Digital Imaging and Communications in Medicine) coordinate system and the TCC system. Both methods use a reference point in the CT coordinate system to correlate a point in the TCC system to perform the coordinate transfer between the two systems. Both methods were used to calculate the TCC and the results were checked against each other, creating an integrated workflow via automated self‐checking. The accuracy of the calculation system was retrospectively evaluated with 275 patients, where the actual treatment position determined with cone‐beam CT was used as a reference. Results: An efficient workflow transparent to the therapists at both CT simulation and treatment was created. It works with any indexed immobilization device and can be universally applied to all treatment sites. The two methods had comparable accuracy, with 95% of the calculations within 3 mm. The inter‐fraction variation was within ± 1.0 cm for 95% of the coordinates across all the treatment sites. Conclusions: A robust, accurate, and streamlined system was implemented to calculate TCCs in advance. It eases the pressure on the treating therapists, reduces patient setup time, and enhances the patient safety by preventing setup errors. [ABSTRACT FROM AUTHOR]

The aim of this article is to present the project of a contrastive Polish-German and Russian-German grammar, which arose as a result of the cooperation between Samara State University of Social Sciences and Education and Adam Mickiewicz University in Poznan. The idea of a unilateral grammar which is based on the categories of the mother tongue of the learner and is aimed at the foreign language to be learned, is designed as a suitable measure within the framework of error prevention. The grammar contains selected grammatical categories that are significant sources of errors for native Slavic speakers. [ABSTRACT FROM AUTHOR]

Assembly errors can occur in a robotic assembly system. In this paper, a method that predicts an assembly error is proposed. It considers that assembly errors occur under the condition that the geometric trajectory of a mated part and the relational position and orientation of a base part are outside the allowable tolerance. A certain point, which is determined by using a physical light reflectance model of a mated part, is followed with two high-speed cameras. A statistical pattern recognition method in which explanatory variables are tracked points in a three-dimensional space is then employed to predict an assembly error. The proposed method is applied to a peg-in-a-hole assembly by a selective compliance assembly robot arm (SCARA)-type robot and its potential value is discussed. [ABSTRACT FROM AUTHOR]

Over the last 50 years, the number of clinical autopsies has decreased, but their role in assessing cause of death and clinical performance is still acknowledged. Few publications have studied their role in malpractice claim prevention. The paper aims to highlight the role of clinical autopsy in preventing errors and improve healthcare quality. A retrospective study was conducted on 28 clinical autopsies performed between 2015 and 2021 on patients dead unexpectedly after procedures for the diagnosis and treatment of digestive and hepatic diseases. After an accurate analysis of medical records and consultation with healthcare professionals, all cases were subjected to autopsy and histopathology. The data obtained were analyzed and shared with the risk-management team to identify pitfalls and preventive strategies. Post-mortem evaluations confirmed the clinical diagnosis only in six cases (21.4%). Discordances were observed in 10 cases (35.7%). In the remaining 12 cases (42.9%) the clinical diagnosis was labeled as “unknown” and post-mortem examinations made it possible to document the cause of death. Post-mortem examinations can concretely enrich hospital prevention systems and improve patient safety. The methodological approach outlined certainly demonstrates that, even in the risk-management field, “mors gaudet succurrere vitae” (“death delights in helping life”).

This article discusses the process of Failure Mode and Effects Analysis (FMEA) and how it relates to performance improvement (PI) and the development of high reliability organizations. As a proactive process, PI team members can use FMEA to identify and prioritize risk before errors occur in health care environments. This tool comprises steps to assess the failure risk of a process, system, or function before the failure occurs. Performance improvement team members can use FMEA as an additional tool to guide them when working to create a culture of safe patient care and improve patient outcomes. After reviewing this article, the reader should have a better understanding of FMEA, how to implement it, and how it supports PI processes and high reliability organizations. This is the fourth article of a six‐part series about performance improvement. [ABSTRACT FROM AUTHOR]

Surgical specimen management is an important responsibility of perioperative nurses and is essential to the provision of safe, quality patient care. Errors related to surgical specimen management can lead to a variety of negative consequences for patients and personnel. Unfortunately, surgical specimen management errors can and do occur, particularly during the preanalytic phase, and thus are a major perioperative patient safety concern. The overall management process for various surgical specimens is essentially the same, requiring a multifaceted, multidisciplinary, standardized method that includes specimen identification, labeling, collection, handling, transferring, containing, and transporting. For perioperative nurses to advocate for their patients and help ensure effective surgical specimen management, effective communication among care team members is imperative, along with a culture of safety that focuses on the minimization of distractions and an increased awareness of opportunities for errors. [ABSTRACT FROM AUTHOR]