Reactions to errors

The examples of poor culture first show the importance attached to culture by experienced clinicians and safety experts. They also illuminate, to some extent, the different facets of culture and the different senses in which the word is used. The first two quotes are primarily concerned with the reaction to errors after they have occurred and the authors are rightly critical of unthinking, heavy handed reactions both inside healthcare organizations and in the wider society we are therefore concerned with the culture of both healthcare organizations and wider social mores. Another theme apparent here is that... 

The leaders able to change their reactions to error are the ones able to advance a culture of safety. The Minnesota Alliance for Patient Safety (2002) defined reduction of medical error as a leadership imperative and an executive responsibility that cannot be delegated. These leaders identified the following requirements to advance safety ... 

FMEAs, Measures to Control Errors and System Reaction to Errors ... 

Despite the variety of methods that had been developed, by 1960 kinetic methods were no longer in common use. The principal limitation to a broader acceptance of chemical kinetic methods was their greater susceptibility to errors from uncontrolled or poorly controlled variables, such as temperature and pH, and the presence of interferents that activate or inhibit catalytic reactions. Many of these limitations, however, were overcome during the 1960s, 1970s, and 1980s with the development of improved instrumentation and data analysis methods compensating for these errors. ... 

The overall requirement is 1.0—2.0 s for low energy waste compared to typical design standards of 2.0 s for RCRA ha2ardous waste units. The most important, ie, rate limiting steps are droplet evaporation and chemical reaction. The calculated time requirements for these steps are only approximations and subject to error. For example, formation of a skin on the evaporating droplet may inhibit evaporation compared to the theory, whereas secondary atomization may accelerate it. Errors in estimates of the activation energy can significantly alter the chemical reaction rate constant, and the pre-exponential factor from equation 36 is only approximate. Also, interactions with free-radical species may accelerate the rate of chemical reaction over that estimated solely as a result of thermal excitation therefore, measurements of the time requirements are desirable. 

A more serious problem is that we lose all kinetic information about the system until the data collection begins, and ultimately this limits the rates that can be studied. For first-order reactions we may be able to sacrifice the data contained in the first one, two, or three half-lives, provided the system amplitude is adequate that is, the remaining extent of reaction must be quantitatively detectable. However, this practice of basing kinetic analyses on the last few percentage of reaction is subject to error from unknown side reactions or analytical difficulties. 

The presence of arsenous acid causes a considerable change in the induced reaction the error in the H2O2 determination decreases to a minimum and an As(ril) error appears, while the S2OI error remains practically unchanged. Though reaction between arsenic(III) and peroxydisulphate is about ten times as rapid as that between hydrogen peroxide and peroxydisulphate, the extent of the induced reduction of peroxydisulphate remains practically unchanged. This indicates that, in the induced chain oxidation, reaction (85), is replaced by the more rapid reaction... 

Relaxation methods for the study of fast electrode processes are recent developments but their origin, except in the case of faradaic rectification, can be traced to older work. The other relaxation methods are subject to errors related directly or indirectly to the internal resistance of the cell and the double-layer capacity of the test electrode. These errors tend to increase as the reaction becomes more and more reversible. None of these methods is suitable for the accurate determination of rate constants larger than 1.0 cm/s. Such errors are eliminated with faradaic rectification, because this method takes advantage of complete linearity of cell resistance and the slight nonlinearity of double-layer capacity. The potentialities of the faradaic rectification method for measurement of rate constants of the order of 10 cm/s are well recognized, and it is hoped that by suitably developing the technique for measurement at frequencies above 20 MHz, it should be possible to measure rate constants even of the order of 100 cm/s. 

The rate of reaction at constant volume is thus proportional to the time derivative of the molar concentration. However, it should he emphasized that in general the rate of reaction is not equal to the time derivative of a concentration. Moreover, omission of the 1 / term frequently leads to errors in the analysis and use of kinetic data. When one substitutes the product of concentration and volume for nt in equation 3.0.3, the essential difference between equations 3.0.3 and 3.0.8 becomes obvious. 

It is always wise to calibrate physical methods of analysis using mixtures of known composition under conditions that approximate as closely as practicable those prevailing in the reaction system. This procedure is recommended because side reactions can introduce large errors and because some unforeseen complication may invalidate the results obtained with the technique. For example, in spectrophotometric studies of reaction kinetics, the absorbance that one measures can be grossly distorted by the presence of small amounts of highly colored absorbing impurities or by-products. For this reason, when one uses indirect physical methods in kinetic studies, it is essential to verify the stoichiometry of the reaction to ensure that the products of the reaction and their relative mole numbers are known with certainty. For the same reason it is recommended that more than one physical method of analysis be used in detailed kinetic studies. 

A cycle can be simple, as above, but it is also possible to conceive of series of reactions starting from basic material, X, with an environmental input of energy which produce 2X in each reaction sequence. The process will be open to error unless it is coded, but it is self-expanding (not reproductive) and not totally cyclic. 

The quantitation of products that form in low yields requires special care with HPLC analyses. In cases where the product yield is <1%, it is generally not feasible to obtain sufficient material for a detailed physical characterization of the product. Therefore, the product identification is restricted to a comparison of the UV-vis spectrum and HPLC retention time with those for an authentic standard. However, if a minor reaction product forms with a UV spectrum and HPLC chromatographic properties similar to those for the putative substitution or elimination reaction, this may lead to errors in structural assignments. Our practice is to treat rate constant ratios determined from very low product yields as limits, until additional evidence can be obtained that our experimental value for this ratio provides a chemically reasonable description of the partitioning of the carbocation intermediate. For example, verification of the structure of an alkene that is proposed to form in low yields by deprotonation of the carbocation by solvent can be obtained from a detailed analysis of the increase in the yield of this product due to general base catalysis of carbocation deprotonation.14,16... 

A potentially more sensitive and selective approach involves reaction of formic acid with a reagent to form a chromophore or fluorophore, followed by chromatographic analysis. A wide variety of alkylating and silylating reagents have been used for this purpose. Two serious drawbacks to this approach are that inorganic salts and/or water interfere with the derivatisation reaction, and these reactions are generally not specific for formic acid or other carboxylic acids. These techniques are prone to errors from adsorption losses, contamination, and decomposition of the components of interest. Enzymic techniques, in contrast, are ideal for the analysis of non-saline water samples, since they are compatible with aqueous media and involve little or no chemical or physical alterations of the sample (e.g., pH, temperature). 

Are the equilibrium constants for the important reactions in the thermodynamic dataset sufficiently accurate The collection of thermodynamic data is subject to error in the experiment, chemical analysis, and interpretation of the experimental results. Error margins, however, are seldom reported and never seem to appear in data compilations. Compiled data, furthermore, have generally been extrapolated from the temperature of measurement to that of interest (e.g., Helgeson, 1969). The stabilities of many aqueous species have been determined only at room temperature, for example, and mineral solubilities many times are measured at high temperatures where reactions approach equilibrium most rapidly. Evaluating the stabilities and sometimes even the stoichiometries of complex species is especially difficult and prone to inaccuracy. 

Meanwhile, these chemicals—like chemical agents encountered at work or in hobbies or as pollutants in air, water, soil, or food—can also cause harm. Sometimes the known mechanisms of action permit us to predict the nature of toxicity to be expected. A meta-analysis of prospective studies from U.S. hospitals indicates that 6.7% of in-patients have serious adverse drug reactions 0.3% have fatal reactions (Lazarou et al., 1998). In fact, estimates of 40,000 to 100,000 deaths per year attributed to errors in medical care, primarily due to adverse reactions to pharmaceuticals, make this phenomenon a major cause of death in the United States (Meyer, 2000). A tremendous... 

However, this reaction can and has led to errors in the measurement of RSNOs in biological fluids when the samples are improperly buffered to avoid the HN02 -route to S-nitrosation (Tsikas, 2003). 

There was a thermodynamic preference for the reaction to take place at the terminal alkene carbon, which favors the yield of linear aldehyde, but the TS to linear aldehyde path was higher than the TS for the branched aldehyde path. Regioselectivity was evaluated from the products relative stability, i.e. considering that the reaction is under thermodynamic rather than under kinetic control. The linear to branched ratio (l b) of 94 6 was in excellent agreement with the ratio 95 5 reported for PPh3 [25], However, this nice coincidence must be viewed cautiously because the model is simple, reaction paths were partially considered, so a subtle cancellation of errors may have been made. 

A major source of error in any indirect method is inaccuracy of the basis rate constants. Errors can result from determinations of rate constants by a sequence of several indirect studies or by an unanticipated solvent effect on the kinetics of a basis reaction. An error can also result in calibration of a radical clock if the requisite assumption that the clock radical will react with a rate constant equal to that of a simple model radical is not correct. Nevertheless, indirect methods in general, and radical clock studies in particular, have been the workhorse of radical kinetic determinations. 

In order to determine the errors that may be introduced by the Zeldovich model, Miller and Bowman [6] calculated the maximum (initial) NO formation rates from the model and compared them with the maximum NO formation rates calculated from a detailed kinetics model for a fuel-rich (isothermal system was assumed and the type of prompt NO reactions to be discussed next were omitted. Thus, the observed differences in NO formation rates are due entirely to the nonequilibrium radical concentrations that exist during the combustion process. Their results are shown in Fig. 8.1, which indicates... 

In the previous section, we introduced the way that coulometry can be employed as an analytical tool, looking speciflcally at some simple forms of the technique. We saw that the charge passed was a simple function of the amount of material that had been electromodified, and then looked at ways in which the coulometric experiment was prone to errors, such as non-faradaic currents borne of electrolytic side reactions or from charging of the double-layer. 

A drawback of Gran plots is the fact that all deviations from the theoretical slope value cause an error and that side reactions are not considered. The method was modified by Ingman and Still [63], who considered side reactions to a certain degree, but the equilibrium constants and the concentrations of the components involved must be known. The Gran method is, however, advantageous for determinations in the vicinity of the determination limit The extrapolation of the linear dependence yields the sum + c, where c, is the residual concentration of the test component produced by impurities, dissolution of the ISE membrane, etc. 

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