Unintentional error

Warning Not everything in this book is true. Despite all efforts to get it right, there are unintentional errors and misinterpretations of experimental results. Indeed, the history of biochemistry is replete with accounts of experimental findings that were interpreted incorrectly. Yet, the ideas expressed often stimulated others to develop a more correct picture later. The same is true today. Students should be critical, should look at experimental details, and consult original literature as much as possible. 

The scope of this chapter in restricted to unintentional errors only and does not extend to intentional errors or sabotage. 

Unintentional Error An action committed or omitted accidentally, with no prior thought. 

Reason s approach to human frailties is probably die most well-known approach with two major categories of behaviors being considered unintentional errors such as slips, lapses, mistakes and the noncompliance with work rules and procedures (Reason, 1990, 1998). 

The key to normal operations data is to collect it in a non jeopardy, de-identified manner. Non jeopardy is not immunity I say again - non jeopardy is not immunity The data collected are all in terms of the threat and air management stractme. Threats are external to the individual. Errors are internal, made by the individual. Individuals do not see or report most of the threats that they deal with because they deal with them daily. Example weather if it is 120 degrees on the ramp or if it is minus 20 with ice and snow, the bags still need to be loaded, the engine still needs to be fixed and the crew still needs to do a walk aroimd inspection. Most do not see the weather as a threat they see it as just another lousy day. Mistakes, slips, lapses, commissions, omissions, and other unintentional errors, on the other hand most likely go unreported due to fear of punishment or simply embarrassment. 

Errors of omission may be genuine (unintentional) errors or intentional violations. 

There is a need to improve some of the diagnostic medical techniques. At present, blood samples are sent to a remote laboratory for analysis. This laboratory may be far from the patient and the physician and there are bound to be delays or even unintentional errors in the clinical chemical results. There is a concentrated effort to use miniaturized electronic devices as sensors that could perform chemical analysis inside the body, in real time. Fiberoptics offers an alternative method for performing medical diagnostics inside the body of a patient. In principle, this method may prove to be sensitive, reliable, and cost effective. 

Prescription errors are unintentional mistakes in the prescription, transcription, dispensing, and administration of medications. The patient either receives the medication incorrectly or fails to receive it altogether. Some prescription errors include wrong patient, incorrect medication, inappropriate dose, wrong time, wrong route of administration, and wrong rate of administration. For example, the profile of a patient shows that he is allergic to codeine, and yet he receives Tylenol 3 by an error. 

Potentiostat makes (IR + T ) a constant, may mean q varies unintentionally with time unless IR error electronically compensated. However, math analysts involving diffusion and intermediate radicals difficult and may involve inapplicable assumptions. Spectroscopic methods better radical catchers ... 

A large number of similar cases could be shown in which the court made observations on the statements of mine or of witnesses that differ from the trial report. Since the differing interpretation of the court were always disadvantageous for me, the question must be raised whether we are supposed to believe that these errors were made unintentionally. 

Sample integrity can be compromised because of operational or analytical measurement errors that are unintentional. Intentional tampering may also be a possibility. 

In 1999 there were 2.5 times as many exposures as in 1993. Clonidine was the child s medication in 10% of those under 6 years, 35% of those aged 6-12 years, and 26% of the adolescents. Unintentional overdose was most common in those under 6 years, while therapeutic errors and suicide attempts predominated in those aged 6-12-years and the adolescents. In 6042 symptomatic children (60%), the most common symptoms were lethargy (80%), bradycardia (17%), hypotension (15%), and respiratory depression (5%). Most of the exposures resulted in no effect (40%) or minor effects (39%). There were moderate effects in 1907 children (19%), major effects in 230 (2%), and one death in a 23-month-old child. 

Of 289 patients exposed to excessive doses of methylphenidate, 31% had symptoms, including most commonly tachycardia, agitation, and lethargy (41). No patient developed severe symptoms, although there was a less favorable outcome with intentional versus unintentional exposure. Peak exposure occurred in 6- to 9-year-old children, in whom therapeutic error was the most common reason for exposure. 

In tables which list "/(C-X) values, little effort has been made to include the error in the coupling constant as estimated by the original authors. One should consult the original literature for the experimental details. Although an attempt has been made to mention all of the relevant papers published during this time, some work may have been unintentionally missed. 

A number of factors are believed to increase the risk of drug-related problems in the elderly, including suboptimal prescribing (e.g., overuse of medications or polypharmacy, inappropriate use, and underuse), medication errors (both dispensing and administration problems), and patient medication nonadherence (both intentional and unintentional). The following subsections address suboptimal prescribing and medication nonadherence, the most common problems. 

Contamination In trace analysis, this is the unintentional introduction of ana-lyte(s) or other species which are not present in the original sample and which may cause an error in the determination. It can occur at any stage in the analysis. Quality assurance procedures, such as the analyses of blanks or reference materials, are used to check for contamination problems. 

Human failure can essentially be split into two categories circumstances in which our actions are unintentional and those which are deliberate. Inadvertent actions constitute human error whilst deliberate activities fall into the remit of violation. 

Fig. 3.9 Schematic variation of the g-factor with the magnetic field in the xy-, yz-, and zx-planes in the Schonland method to determine the g-tensor. The variation is shown over a 90 = interval for the angle specifying the orientation of the magnetic field in each plane. For a perfect fit the measured g-factor should agree along the , , and axes in the different planes. A sign error for (g )xy occurs if the crystal is unintentionally mounted for rotation about -z in place of +z, see text for methods to resolve this Schonland ambiguity ...

---