To Err Is Human

To Err Is Human

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2000-03-01

Total Pages: 312

ISBN-13: 0309068371

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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine


I Am Error

I Am Error

Author: Nathan Altice

Publisher: MIT Press

Published: 2017-09-08

Total Pages: 439

ISBN-13: 0262534541

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The complex material histories of the Nintendo Entertainment System platform, from code to silicon, focusing on its technical constraints and its expressive affordances. In the 1987 Nintendo Entertainment System videogame Zelda II: The Adventure of Link, a character famously declared: I AM ERROR. Puzzled players assumed that this cryptic mesage was a programming flaw, but it was actually a clumsy Japanese-English translation of “My Name is Error,” a benign programmer's joke. In I AM ERROR Nathan Altice explores the complex material histories of the Nintendo Entertainment System (and its Japanese predecessor, the Family Computer), offering a detailed analysis of its programming and engineering, its expressive affordances, and its cultural significance. Nintendo games were rife with mistranslated texts, but, as Altice explains, Nintendo's translation challenges were not just linguistic but also material, with consequences beyond simple misinterpretation. Emphasizing the technical and material evolution of Nintendo's first cartridge-based platform, Altice describes the development of the Family Computer (or Famicom) and its computational architecture; the “translation” problems faced while adapting the Famicom for the U.S. videogame market as the redesigned Entertainment System; Nintendo's breakthrough console title Super Mario Bros. and its remarkable software innovations; the introduction of Nintendo's short-lived proprietary disk format and the design repercussions on The Legend of Zelda; Nintendo's efforts to extend their console's lifespan through cartridge augmentations; the Famicom's Audio Processing Unit (APU) and its importance for the chiptunes genre; and the emergence of software emulators and the new kinds of play they enabled.


ATC System Error and Appraisal of Controller Proficiency

ATC System Error and Appraisal of Controller Proficiency

Author: William F. O'Connor

Publisher:

Published: 1965

Total Pages: 20

ISBN-13:

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The report presents suggestions for the design of an air traffic control (ATC) incident-reporting system aimed at maximizing the amount of corrective feedback to the ATC system. The approach taken is system-oriented rather than controller-oriented. Included is a discussion of a philosophy of corrective and punitive action relative to controller involvement in an incident. Recommendations and examples of format are included for the design of incident-report forms and incident chronology and of a checklist to be used in periodic appraisal of controller performance. Emphasis is given in format design to use of systems and human function, rather than regulatory and procedural terminology. Implementation and data-analysis techniques are also discussed. (Author).


Improving Diagnosis in Health Care

Improving Diagnosis in Health Care

Author: National Academies of Sciences, Engineering, and Medicine

Publisher: National Academies Press

Published: 2015-12-29

Total Pages: 473

ISBN-13: 0309377722

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Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.


Error Control Systems for Digital Communication and Storage

Error Control Systems for Digital Communication and Storage

Author: Stephen B. Wicker

Publisher:

Published: 1995

Total Pages: 536

ISBN-13:

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For introductory graduate courses in coding for telecommunications engineering, digital communications. This introductory text on error control coding focuses on key implementation issues and performance analysis with applications valuable to both mathematicians and engineers.


B2B Integration

B2B Integration

Author: Christoph Bussler

Publisher: Springer Science & Business Media

Published: 2013-06-29

Total Pages: 428

ISBN-13: 3662051699

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Business-to-business (B2B) integration is a buzzword which has been used a lot in recent years, with a variety of meanings. Starting with a clear technical definition of this term and its relation to topics like A2A (Application-to-Application), ASP (Application Service Provider), A2A, and B2C (Business-to-Consumer), Christoph Bussler outlines a complete and consistent B2B integration architecture based on a coherent conceptual model. He shows that B2B integration not only requires the exchange of business events between distributed trading partners across networks like the Internet, but also demands back-end application integration within business processes, and thus goes far beyond traditional approaches to enterprise application integration approaches. His detailed presentation describes how B2B integration standards like RosettaNet or SWIFT, the application integration standard J2EE Connector Architecture and basic standards like XML act together in order to enable business process integration. The book is the first of its kind that discusses B2B concepts and architectures independent of specific and short-term industrial or academic approaches and thus provides solid and long-lasting knowledge for researchers, students, and professionals interested in the field of B2B integration.


Host-based IDS - tripwire, aide

Host-based IDS - tripwire, aide

Author: Noite.pl

Publisher: NOITE S.C.

Published:

Total Pages: 29

ISBN-13:

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Tracking modification of files with AIDE or Tripwire is one of the main methods of protecting the system. The micro-course describes popular Host IDS systems, tripwire and AIDE. These are programs for local analysis of the file system and informing the administrator about changes in it. Keywords: aide, tripwire, Host IDS Host-based IDS - tripwire, aideTripwireTripwire installationAIDE (Advanced Intrusion Detection Environment)


WebSphere MQ V6 Fundamentals

WebSphere MQ V6 Fundamentals

Author: Saida Davies

Publisher: IBM Redbooks

Published: 2005-12-15

Total Pages: 446

ISBN-13: 073849299X

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This IBM Redbooks publication describes the fundamental concepts and benefits of message queuing technology. This book is an update of a very popular Redpaper (REDP-0021) based on IBM WebSphere MQ Versions 5.0 to 5.2. This publication provides a design-level overview and technical introduction for the established and reliable WebSphere MQ product. A broad technical understanding of the WebSphere MQ product can improve design and implementation decisions for WebSphere MQ infrastructures and applications. To reduce the time required to gain this understanding, this book summarizes relevant information from across the WebSphere MQ product documentation. We also include hands-on security and troubleshooting sections to aid understanding and provide a reference for common administrative actions performed when building and maintaining WebSphere MQ infrastructures. In the appendix, we provide a summary of the new features in WebSphere MQ Version 6.0.


Aircraft Communications and Navigation Systems

Aircraft Communications and Navigation Systems

Author: Mike Tooley

Publisher: Taylor & Francis

Published: 2024-03-28

Total Pages: 383

ISBN-13: 1003813070

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Introducing the principles of communications and navigation systems, this book is written for anyone pursuing a career in aircraft maintenance engineering or a related aerospace engineering discipline, and in particular will be suitable for those studying for licensed aircraft maintenance engineer status. It systematically addresses the relevant sections (Air Transport Association of America chapters 23/34) of modules 11 and 13 of part-66 of the European Aviation Safety Agency (EASA) syllabus and is ideal for anyone studying as part of an EASA and FAR-147-approved course in aerospace engineering. Delivers the essential principles and knowledge base required by Airframe and Propulsion (A&P) Mechanics for Modules 11 and 13 of the EASA Part-66 syllabus and BTEC National awards in aerospace engineering Supports mechanics, technicians and engineers studying for a Part-66 qualification Comprehensive and accessible, with self-test questions, exercises and multiple choice questions to enhance learning for both independent and tutor-assisted study Additional resources and interactive materials are available at the book's companion website at www.66web.co.uk This new and updated third edition provides readers with an overview of the latest key technologies that underpin the functioning of safety-critical systems such as those used in flight management, reporting, navigation, and air traffic control.