Error Reporting

In his survey of the use of CRMs in food related publications on the subject of trace elements for the years 1990-1996, Jorhem (1998) checked 82 papers published in five international journals. He found that in 42 papers there was no mention of CRM results and assumed that no CRMs were used. He wrote Since the importance of incorporating CRMs in the AQA-activities today is well recognized, it is surprising that firstly so many laboratories still do not use CRMs and secondly that scientific journals accept papers describing analytical results without the use of reference materials, as part of the verification of the analytical results . 

---

Assumptions used to group reported errors to represent the error being analyzed,... 

Thorough training, including realistic practical exercises, with participation of outside services, is advisable. A full-scale rehearsal at least once a year is recommended. (Modifications can subsequently be introduced to cater for reported errors and omissions.)... 

Despite all efforts, some errors or misleading passages will still have remained. Mistakes are an attribute that make us human, but unfortunately, they do not contribute to the scientific or educational value of a textbook. Therefore, please do not hesitate to report errors to me or to drop a hne of comment in order to allow for corrections in a future edition. 

Health care professionals report errors in which they are involved as well as errors that they observe or are party to. Reported information forms a database used by USP to identify problematie situations, heighten practitioners awareness of these situations, and make appropriate interventions regarding issues with drug products. 

In the reported error, a physieian used the abbreviation IL-ll when ordering oprelvekin for a patient. Unfortimately, the order was misinterpreted to be interleukin-2 (i.e., the number eleven was pereeived to be the Roman numeral two). Five or more health eare professionals, ineluding pharmacists and nurses, mistook the order to be aldesleukin. The error was not detected for four days, until it was noted that the inventory of aldesleukin was nearly depleted. 

To assess the effect of sloppy loading of slides into the platen of the Ventana, a series of bar-coded slides were placed into the slide holders on the platen at a variety of angles or placed on the instrument unclipped into the slide holders. In all cases, when the instrument scanned the slides, it reported error conditions and would not allow the staining run to proceed. 

In the absence of reported errors, the three activity value fields are equal. The decision to index these values for each molecule was taken because missing values are given a different interpretation by statistical techniques. 

Root Mean Square Error of Calibration (RMSEC) Plot (Model Diagnostic) The RMSEC as a function of the number of variables included in the model is shown in Figure 5-77. It decreases as variables are added to the model and the largest decrease is observed between a one- and two-variable model. The reported error in the reference caustic concentration is approximately 0.033 vrt.% (la). The tentative conclusion is that four variables are appropriate because the RMSEC is less than the reference concentration error after five variables are included in the model. 

After drugs are approved, the FDA tracks reports of errors due to drug name confusion and spreads the word to health professionals, along with recommendations for avoiding future problems. For example, the FDA has reported errors involving the inadvertent administration of methadone, a drug used to treat opiate dependence, rather than the intended Metadate ER (methylphenidate) for the treatment of attention-deficit/hyperactivity... 

Table 1.1 shows that much of the work has been done on hydrocarbons and, in particular, homologous series. As a result, several very accurate methods are available for estimating the melting points of normal alkanes. For example, Broadhurst (1962) reports errors of less than 0.5°C for paraffins with chain lengths between 44 and 100 carbons. Similarly, Hanson... 

It is also possible to report errors in terms of quality of modelling of spectra (or chromatograms), often called the x block error. 

The report drafting should not be kept for last it is rather time consuming due to the detailed reporting requirements that have to be met. Under time pressure, an error may easily creep in and subsequently lower the participant s final score. Reporting errors may be avoided by implementing a... 

The current penalty system is strict, clear, and straightforward however, it does not allow for minor errors. In fact, minor errors are treated equally to a false negative result, as demonstrated with the following example Laboratory 1 failed to identify one of the spiking chemicals in a test. Laboratory 2 found all spiking chemicals however, it made a minor reporting error in the identification of one of them the evidence provided was adequate to indicate the presence of the particular chemical, however, did not fulfill all the reporting requirements. 

Since the degree of coupling is directly proportional to the product Q (D/k)in, the error level of the predictions of q is mainly related to the reported error levels of Q values. The polynomial fits to the thermal conductivity, mass diifusivity, and heat of transport for the alkanes in chloroform and in carbon tetrachloride are given in Tables C1-C6 in Appendix C. The thermal conductivity for the hexane-carbon tetrachloride mixture has been predicted by the local composition model NRTL. The various activity coefficient models with the data given in DECHEMA series may be used to estimate the thermodynamic factors. However, it should be noted that the thermodynamic factors obtained from various molecular models as well as from two sets of parameters of the same model might be different. 

Voluntary reports are usually made by the person who detects the error. In many organizations, individuals are afraid to report errors, because there is fear that they might be associated with disciplinary actions. An anonymous reporting program may promote better error reporting. 

A proactive approach for medicahon safety promotes a nonpunitive culture, wherein errors and near misses can be reported and safety improved. Prac-tihoners need to be assured by their organization that reporting errors is encouraged, individuals will not be punished for system failures, and improvements will be made to prevent future errors. 

The Medication Error Reporting Program (MERP) is a voluntary program administered by the U.S. Pharmacopeia (USP) in conjxmction with the ISMP. This confidential reporting system improves patient safety by alerting practitioners and the industry to potential or actual problems. Practitioners are asked to report errors and near misses to this program so that others learn from errors and prevent similar errors in the future. 

---