Catastrophic errors

It is important to understand the demands of a job on a person s time before increasing the span of control. If the change to the scope of a job means that the person will be less available to the people who rely on them, then it may encourage people to find alternative options. On the positive side, this can sometimes empower people within their own jobs and require less assistance. However, it can also mean that people conduct their business with a lack of information or rely on incorrect sources which can lead to catastrophic errors. 

The total number of symmetries is therefore equal to a = 12x81 = 972. The entropy correction which follows from this equals = - 8.315 x In 972 = - 57.2 J mol l K T Forgetting this correction for very symmetrical chemical species would therefore result in a catastrophic error. 

Despite the relative lack of information about side effects related to pharmacy prepared products, there have been reports of catastrophic errors associated with them, including an error in the US that led to a 1,000-fold overdose of clonidine in a 5 year old child [1]. A high profile error also occurred in 1998 in the UK, when a baby died following a calculation error in preparing peppermint water in a community pharmacy [2]. 

The application of the science of human factors to eliminating error in all aspects of process design, management, operation, and maintenance is the focus of this work. Human error has been a major cause of almost all of the catastrophic accidents that have occurred in the chemical process industries (CPI). If one adopts the broad view of human error as being the result of a mismatch between human capabilities and process demands, then clearly management s role is critical in the following areas ... 

The consequences of an external error mode will depend on the context in which it occurs. Consequences for the same error may be trivial (near misses) or catastrophic, depending on the design of the plant and the recoverability of the error. In the example under consideration, a serious accident occurred. 

Contacting Uie manufacturer would help clarify any uncertainUes concerning the chemicals being used mid could also, in Uie event Uiat it has been discovered Uiat Uic manufacturer lias made an error in the production or delivery of a certain chemical, prevent a potential catastrophe elsewhere caused by the use of the same chemical. 

PREPARE error. PREPARE file full - non-catastrophic, program continues. 

In principle, numerical methods can be employed to evaluate inverse Laplace transforms. However, the procedure is subject to errors that are often very laige-even catastrophic. 

A hypercycle is a more complex organisation form. Its precondition is the presence of several RNA quasi-species which are able to amalgamate chemically with certain proteins (enzymes or their precursors). If such a protein is linked to a quasi-species, the resulting duo favours the replication of a second quasispecies. According to Dyson, the linked populations get stuck in a stable equilibrium. Problems occur at this level Any theory on the origin of replication has the central problem that the replication process must occur perfectly in order to ensure survival . If there are replication errors, these will increase from generation to generation, until the system collapses the error catastrophe has then occurred ... 

If it is not fulfilled, the error catastrophe occurs. On the left-hand side of the equation is the number of bits of information which the system loses if the errors are copied in each new generation. The right-hand side corresponds to the number of bits which are caused by selection. 

Doubts about the problem of the error catastrophe were expressed in Freiburg im Breisgau. Computer simulations showed that, apart from the error catastrophe, other fatal events threaten evolving populations (Bresch et al., 1980 Niesert et al., 1982 ... 

Every step in this method is critical to the development of a safe design an error in any step of this procedure can result in catastrophic failures. 

Physical property data and sometimes reaction rate characteristics are required for making relief sizing calculations. Data estimated using engineering assumptions are almost always acceptable when designing unit operations because the only result is poorer yields or poorer quality. In the relief design, however, these types of assumptions are not acceptable because an error may result in catastrophic and hazardous failures. 

Fast R, Eberhard TH, Ruusala T, Kurland CG (1987) Does streptomycin cause an error catastrophe . Biochimie 69 131-136... 

This all explains the nature of failures of the DFT based methods in those cases, when correlations substantially come into play as in e.g. d -iron (II) ferrocene molecule. Here the errors even of advanced DFT methods become catastrophic. For example, in Ref. [86] the calculated enthalpies of dissociation of ferrocene to the free Fe + ion and two Cp anions (Cp = C5H5 - cyclopentadienyl) depending on the functional used appear to be by 3-4 eV smaller than the experimental value. The reason is transparent... 

The film The Fog ofWar (2004) starts with Robert McNamara, US Secretary of Defense in the 1960s, saying that military commanders always make mistakes and errors of judgement which can lead to the loss of hundreds of thousands of lives. However, with modern nuclear weapons those mistakes would destroy nations. In the extreme situation of war it is possible to regard the loss of many lives as not catastrophic, but destruction of the nation fighting the war is. 

A failure that may be of technical origin or stem from human error, either during the operation or during process design. External events, such as weather conditions or natural catastrophe may also be at the origin of a failure. 

Catastrophic medication errors, particularly when someone dies, are a newsworthy event. Health care is not immune. Such errors are not likely to remain secret. As a result of the adverse public exposure, reputations will be diminished, with potentially significant consequences for individual practitioners and institutions. The only means available, at least initially, to rehabilitate individual and institutional reputations is an appropriate message and response through the media. 

As a practical matter, a successful response to a catastrophic medication error proceeds through the following stages ... 

Signal detection. Catastrophic medication errors should not be a surprise. Routine and noncatas-trophic errors foreshadow the inevitable. 

Preparation and prevention. The best organizations do all they can to prevent catastrophic medication errors while recognizing that they must prepare and plan for their inevitable occurrence. 

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