Error wisdom

The idea of teaching specific safety attitudes and behaviours is unusual in healthcare but deeply embedded in a number of hazardous industries. For instance, the Western Mining Corporation in Western Australia is an exemplar of creating error wisdom within its organization and front line staff. Their motto is Take time, take charge, which aims to get workers to stop and think, to... 

Reason, J. (2004) Beyond the organisational accident the need for error wisdom on the front line. Quality and Safety in Health Care, 13(suppl 2), ii28-ii33. 

Maybe if we keep on learning from our mistakes, Liz and 1 can get smart enough to stop making errors. Wisdom comes with age. As long as we both remember that we are not too old to learn, we ll be okay. 

It has become an accepted wisdom that the use of RMs or CRMs will help to improve the accuracy and precision of an analytical process. This belief has led to a rapid growth in the use of RMs and CRMs in commercial laboratories. The authors and many analysts the world over support this view, but also recognize that in far too many cases inexperience and carelessness conspire together with the result that error accumulates and often unreliable data are produced. 

The data of Table 5.4 have been reworked again in Table 5.6, which includes the total cations, total anions, total ions, and reaction errors. The data in Table 5.4 have been expressed in meq/1. However, most people are used to the mg/1 units for assessment of the degree of salinity of water. The conversion of meq/1 data into mg/1 was discussed in section 5.6, and is here demonstrated on the Wisdom Spring data (Table 5.7) ... 

Table 5.6 Total Ions (meq/1) and Reaction Errors, Calculated for the Wisdom Spring Data (Table 5.4)...

As stated, reaction errors are another way to estimate data quality (section 5.8). The reaction error can (and should) be better than 1%, but they are often larger. Many investigators will accept up to 5%. Using the latter criterion the reaction errors calculated in Table 5.6 (4.3%, 3.3%, 2.1%, 1.2%, and 1.6%) are acceptable. This example brings out a major shortcoming of the reaction error quality test the poor reproducibility of the S04 data, demonstrated above, is not reflected in the reaction error because SO4 is a minor compound of the Wisdom Spring water. Low reaction errors indicate acceptable quality of the data for the major ions alone. 

After you ve checked for these obvious errors, take a second look at the more difficult questions. You ve probably heard the folk wisdom about never changing an answer. If you have a good reason for thinking a response is wrong, change it. 

This book tries to go beyond collecting and compiling accepted wisdom. In every instance it attempts to evaluate prior art critically, and in large parts it presents new methodology that has yet to withstand the acid test of extensive practical application. All this has required judgment calls. With much own experience and good advice to draw on, I am confident the big picture is correct. If there are errors in detail, I must accept sole responsibility, even where other sources are quoted. 

More sensitive to the level of theory is the vibrational component of the interaction energy. In the first place, the harmonic frequencies typically require rather high levels of theory for accurate evaluation. It has become part of conventional wisdom, for example, that these frequencies are routinely overestimated by 10% or so at the Hartree-Fock level, even with excellent basis sets. A second consideration arises from the weak nature of the H-bond-ing interaction itself. Whereas the harmonic approximation may be quite reasonable for the individual monomers, the high-amplitude intermolecular modes are subject to significant anharmonic effects. On the other hand, some of the errors made in the computation of vibrational frequencies in the separate monomers are likely to be canceled by errors of like magnitude in the complex. Errors of up to 1 kcal/mol might be expected in the combination of zero-point vibrational and thermal population energies under normal circumstances. The most effective means to reduce this error would be a more detailed analysis of the vibration-rotational motion of the complex that includes anharmonicity. 

My new colleague. Dr. Eric Kantorowski, has reviewed the entire manuscript for accuracy and style. His diligence, attention to detail and chemical wisdom have made this a better manual. Eric stands on the shoulders of previous reviewers who scoured earlier editions for errors Jessica Gilman, Dr. Kristen Meisenheimer, and Dr. Dan Mattern. Mr. Richard King has offered numerous suggestions on how to clarify murky explanations. 1 am grateful to them all. 

As this Septenary is crowned with the two Sublime Virtues of Wisdom and Understandings so two dark manifestations oppose them. These are against Understandings Blindness of x ie Spirit), and against Wisdoms (fundamental) Error,... 

We saw there that Blindness opposes Understandings and the Silver of the Wise and Error opposes Wisdom and Sulfur or x t Gold of the Wise. 

Hindsight bias and memory failure Extreme over-confidence Vulnerable to environmental influences Lack of control over thought and action Flexibility and adaptability Experience and wisdom Anticipation of hazards Recovery from error... 

The HazOp study differs from the FMEA and ETBA in that some suggest that the best time to conduct a HazOp is when the design is fairly firm (Goldwaite 1987). Conventional system safety wisdom dictates that the system safety effort be as far upstream as practical, with a facility preliminary hazard analysis developed as part of the initial design effort and completed by the 35% stage. Also, a HazOp study tends to include human factors and operator errors whereas a traditional FMEA or ETBA normally examines hardware failures only. 

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