• Title/Summary/Keyword: omission of critical information

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Errors in Surgical Pathology Reports: a Study from a Major Center in Pakistan

  • Ahmad, Zubair;Idrees, Romana;Uddin, Nasir;Ahmed, Arsalan;Fatima, Saira
    • Asian Pacific Journal of Cancer Prevention
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    • v.17 no.4
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    • pp.1869-1874
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    • 2016
  • Background: Errors in surgical pathology diagnosis can have serious consequences for the patient. Since the final product of a surgical pathology lab is the report, errors can be picked by reviewing reports of cases. Aim: To determine the frequency and types of error in surgical pathology reports of cases signed out in 2014 in a laboratory in Karachi, Pakistan. Materials and Methods: All surgical pathology reports in which changes were made in the original report after sign out and an amended report was issued were included. Errors included: (1) misinterpretations; (2) missing critical information; (3) erroneous critical information; (4) misidentification; and (5) typographic errors. Results: Errors were identified in 210 cases (0.37%). These comprised 199 formalin fixed specimens and 11 frozen sections. The latter represented 3.8% of a total of 2,170 frozen sections. Of the 11 frozen section errors, 10 were misinterpretations. Of the 199 permanent specimens, 99 (49.7%) were misinterpretations, 65 (32.7%) belonged to missing critical information category, 8 (4%) belonged to erroneous critical information category, 8(4%) were misidentifications, 16(8%) were typographic errors while 3 cases (1.5%) were other errors. Most misinterpretations occurred in the gastro intestinal, liver and pancreato biliary tract (23.2%) and breast (13.1%). Another 87 cases were reviewed on the clinicians' request. However diagnosis after review remained the same as the original diagnosis. In 49 out of these (56.3%), additional workup was performed at the time of the review. Conclusions: Our findings were similar to other published studies. We need to develop documented procedures for timely review of cases to detect errors.

Failure Analysis of Aircraft Software Test Cases from a Perspective of Requirements Traceability (요구사항 추적성 관점에서 항공기 탑재 소프트웨어 시험 사례 실패 분석)

  • Kim, Sung-Sub;Cho, Hee-Tae;Lee, Seonah
    • KIPS Transactions on Software and Data Engineering
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    • v.9 no.11
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    • pp.357-366
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    • 2020
  • As the proportion and complexity of software embedded in aircraft increase, risk factors such as mission failure, function failure and performance failure due to software errors also increase. In the mission-critical software systems such as aircraft software, managing requirement traceability is essential to maintain the software systems with minimal period and cost. However, the development company is not accurately complying with the guideline for managing requirement traceability due to various reasons such as development cost and schedule. Therefore, it is not easy to systematically establish and maintain requirement traceability. In the paper, we analyze actual test cases of aviation software systems from the viewpoint of requirements traceability in order to learn if there are failure cases of test cases due to the absence of systematic traceability management activities. We also check the risks associated with the failure cases according to the type and severity of the cases. As a result of analyzing a total of 7 aircraft-mounted software, failure cases could be divided into three types: omission of requirements, lack of connection between requirements and test procedures, and omission of test procedures. There were a total of 18 failure cases, 6 for each type. The numbers of high, middle and low risks were 1, 13 and 4, respectively, where the number of middle risks is largest.

Derivation of Methodology Tailoring Rules in Healthcare Industry (의료업에 있어서 방법론 테일러링 규칙의 도출)

  • Choi, Won-Young;Kim, Soon-Gohn
    • Journal of Digital Contents Society
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    • v.12 no.4
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    • pp.593-600
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    • 2011
  • In the case of the domestic medical industry, work is conducting according to the convenience of the developer without guiding principles regarding tailoring and a number of processes and products that should not have been omitted considering the characteristics of corresponding sites were discovered. As a result of this omission, it was found that the delivery period was not met and problems arose for an extensive period of time after the activation of the system. The lack of critical processes and products had a negative impact on the productivity and quality of the software. This paper defines the processes that need to be followed as a basis and the products that need to be prepared during the development of a medical information system. Also, additional processes and products are presented depending upon the condition of the project. Especially, the step-by-step assessment processes and products to manage the assessment results were seriously dealt with in this study to strengthen the compliance of processes and the product quality.

A SOA-based Application Model for Building Intelligent Construction Supply Chain Management Framework (지능형 건설물류관리 체계 구축을 위한 SOA 적용 모델 개발)

  • Shin, Tae-Hong;Chin, Sang-Yoon;Yoon, Su-Won;Kwon, Soon-Wook;Kim, Yea-Sang
    • Proceedings of the Korean Institute Of Construction Engineering and Management
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    • 2008.11a
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    • pp.733-737
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    • 2008
  • Construction supply chain management focused on materials in construction industry plays a critical role which controls the success and failure of a project. For the efficiency of construction supply chain management, the framework which provides project participants with the information originated from whole construction logistics steps without the omission and discontinuation of information flow is required. The new management framework that can support this environment is necessary because of setting up the complicated and distributed environment including logistics information management by intelligent equipment, co-working management with pre-framework legacy system and various devices(UMPC and PDA etc.) as the information confirmation and electrical transmission tool between the project participants different from former construction supply chain management environment while recently developing ubiquitous technologies such as RFID/USN and intelligent equipment to support logistics process. Therefore, the objective of this study is to introduce the concept of SOA (Service Oriented Architecture) as an alternative of effective information integration under the complex and distributed environment and to propose the SOA-based application model for building intelligent construction supply chain management framework.

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A Study on model for Records Management of Local Assembly to Embody Local Governance (로컬 거버넌스 실현을 위한 지방의회 기록관리 모형에 관한 연구)

  • Choi, Youn-Ju
    • The Korean Journal of Archival Studies
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    • no.14
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    • pp.241-288
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    • 2006
  • For cope with the participating government promoted local decentralization of the present time, local governments are coming to aim at the realization of local governance. Local governance refers to a way of solving public problems of urban area through partnership which is a collaboration and participation based on 'relationship' among diverse interested parties such as executive authority of policy, private sectors. First of all, it is most important task to make transparency and responsibility of all people and networks by themselves through sharing information. With like this kind of a background, local assembly is an momentos body of local governance because it is a decision making organization at the same time as a representative organization of local residents, and it has a relationship of 'check and balance' with chiefs of local governments as an organization monitoring and supervising the administration of an executive authority. Not the less, information about local assembly does not open to the public or exist. Even some informations open to the public, they are not enough to be settled distrust and low-valuation by civil society. Now Local assembly is face to a point that improve over all of record management. This study is based like this critical mind, then, it examines throughly local assembly's realities by suggestion with reforming plan of record management. Record can embody true values when record management practices indefatigably through prudential system from production until preservation. Accordingly, this study suggests management of transaction unit without the omission of record. Also this study is satisfy the condition of Korean record management system with proposals of record management policy and establishment of record center. At the conclusion of study, it puts effects into shape that local assembly secure transparency and responsibility and organize local governance by record management.

Prehistoric subsistence and pottery use in the ancient Korean Peninsula: New evidence from organic geochemical analysis of potsherds (토기 내 잔존유기물을 활용한 한반도 선사·고대의 토기 사용과 식생활에 관한 연구)

  • Kwak, Seungki;Shin, Sookjung
    • Korean Journal of Heritage: History & Science
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    • v.52 no.3
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    • pp.146-159
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    • 2019
  • This study focuses on the understanding of human subsistence and pottery use during ancient times on the Korean peninsula through lipid analysis of potsherds from several major prehistoric settlement sites. Ancient human subsistence has been one of the long-standing topics in Korean archaeology. However, since the high acidity of sediments does not allow long-term preservation of organic remains, we still lack some critical information related to the prehistoric diet. Pottery contains relatively well-preserved organic remains created during past cooking events. Though pottery is one of the most studied material cultures in Korean archaeology, almost no attention has been given to analyzing the pottery itself. This is a surprising omission and represents a serious gap in our understanding of prehistoric technology and subsistence. The analysis of ancient lipids extracted from the pottery matrix using GC-MS and isotope analysis can contribute to our understanding of the true nature of past subsistence strategies. Potsherd samples for the analyses in this study were collected from six prehistoric and early historic settlement sites located in the central part of the Korean peninsula. The results showed that subsistence strategies differed by both location and time period. For example, at Jungdo, an inland open-air Bronze Age settlement site in Chuncheon City, we were able to see the presence of terrestrial mammals. At Gahak-dong, Gwangmyeong City, marine resources were utilized, as the location of the site is not far from the coastline. At the early historic site of Guwol-dong, Incheon City, we were able to detect dairy products. The results of this study suggest that there was utilization of a wider range of resources among ancient dwellers in the central part of the Korean peninsula.