Errors that hit the headlines

UCLA is blaming human error for a message that told nearly 900 high school students they’d been accepted to the university when they hadn’t. You can just imagine the reaction in 894 homes, where eager teenagers had applied for admission to UCLA. An email was sent over the weekend to tell those students about expanded financial aid, but a line at the bottom of the email said, “once again, congratulations on your admission to UCLA.”

“We hope this information will assist you in making your decision to join the Bruin family in the fall,” it went on. Almost immediately, the school realized its mistake. Those students had not been admitted but were on a waiting list — and no one on that list will hear anything before next month. In a follow-up email, the school apologized, saying that they acknowledged what an anxious time this can be for students and their families. This foul-up comes barely a week after UCLA mistakenly deposited double the correct amount of financial aid into 7,000 students’ bank accounts, a $27 million error. Those transactions were quickly reversed.

89.33KPC, 11/4/2012

Across the state, hospitals and healthcare centers are ditching pen and paper in favor of using bar codes and other systems to reduce errors in administering medication to patients. Starting in 2008, the Hospital of Central Connecticut was at the forefront of the trend by taking on the bar-code system, a project that cost close to $6 million. During the four years since, hospital officials have noticed a drop in errors associated with administering medication, said Jennifer Clark, a medical informatics officer at the hospital, which includes New Britain General and Bradley Memorial, in Southington. “Mistakes can happen. The majority of mistakes are when the nurse selects the medications for the patient,” Clark said. “Bar-coding prevents that mistake from happening.”

When patients are admitted, they’re given an ID bracelet that includes their name and a bar code. A nurse scans the bar code with a hand-held scanner to make sure that the patient is given the right medication at the right time. “If the nurse pulls out the wrong medication or even if she pulls out the right medication at the wrong time, the scanner will say ‘Error,’ ” Clark said. “It’s a huge improvement on patient safety.”
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An Antonov An-24 aircraft crashed in August 2011 near the Russian city of Blagoveshchensk, in Russia’s Far East. An investigation started by the International Aviation Committee has concluded that the aircraft failed the landing due to a variety of human mistakes by the pilots. One of them, the co-pilot, was performing his first flight after a long pause without necessary training. Twelve out of 36 passengers onboard were injured during the incident which almost totally destroyed the aircraft. According to the investigation, the pilots had to decide whether to go-around, but then they began descending through high turbulence to an altitude “Significantly lower than the decision altitude”, with no ground references visible because of heavy rain. The pilot’s slow reaction to a TAWS (Terrain Awareness and Warning System) alarm, in addition to a lack of precise visibility, cloud height, wind strength and direction information led to the crash landing.

Avionews, 6/4/2012

Officials say human error is the reason dozens of E-ZPass customers got charged 100 times what they owed for a toll charge on the Downtown Expressway. We’ve learned 74 customers were charged $70 instead of 70 cents in one of the plaza’s new E-ZPass lanes. The problem lane was lane 44, a new lane on the westbound travel side. It happened March 22 though March 26.

We tracked down one victim, Tammy Johnson, who counts on the convenience of the E-ZPass lanes, because she passes through them 6 times a day. Tuesday, she said she had a problem getting through the tolls. “The man looked at me like I was crazy,” said Johnson. “He looked at the light like I can’t go through and I was like, ‘No, I got a smart tag!’” Turns out she saw red, because her tag was in the red.

Officials with the Richmond Metro Authority say they were to blame. Someone manually entering fees misplaced a decimal, charging E-ZPass customers $70 dollars instead of 70 cents to pass through. “It is an expensive toll when actually our toll here is 70 cents,” sighed Linda McElroywith the Richmond Metropolitan Authority. “The good news is that we caught the issue early and are able to rectify that situation with those 74 customers.” Johnson says she just wants her money back…and the convenience of being able to use her E-ZPass again. “I have to go through the exact change lanes which are always longer, which are putting an extra five or 10 minutes onto my busy schedule,” said Johnson. “I’m a working mom. Every minute counts.” Officials say this shouldn’t be a problem again — they’ve transitioned to automatic withdrawals on the new toll now, and they say they’ve never seen an error like this one with that system. The Richmond Metropolitan Authority says it takes full responsibility for this mistake and they say all impacted customers should have their money back. Some customers did have automatic replenishment, which means money automatically goes into their E-ZPass accounts when a balance gets low. E-ZPass officials say they’re still figuring out the best way to refund that money.

NBC12, 4/4/2012

18 months after the naked and decomposing body of an MI6 spy was found locked inside a holdall the police have still not been able to establish how he died. The body of Gareth Williams, a GCHQ codebreaker, was found inside the locked holdall in the bathtub of his Pimlico flat on August 23, 2010. Toxicology tests and an exhaustive investigation into his background have been hampered by key blunders, the coroner’s court has heard during a pre-inquest review. Westminster Coroner’s Court was told that Mr William’s MI6 employers failed to raise the alarm when he didn’t report for work leading to delays in finding his body, which resulted in a post mortem being “ineffective”. But in another key blunder, DNA found on the spy’s hand, thought to be crucial to the case, turned out to be from a forensic scientist who took evidence at the scene. Then human error in the way DNA results was fed into a computer led to false leads being pursued needlessly until this year. Coroner, Dr Fiona Wilcox, told the hearing that whether Mr Williams was alive inside the bag and locked it himself “was at the very heart of this inquiry”.

4rfv.co.uk, 30/3/2012

Three hundred Danes who thought they’d won enough money on the lottery to last them several lifetimes were brought down to earth with a bump minutes later when they learnt their actual prizes wouldn’t even pay for a weekend break. State lottery company Danske Spil blamed “human error” for a glitch that held out the promise for part of Tuesday of jackpots ranging from an astronomical 1 billion Danish crowns to a mind-blowing 280 billion ($49.7 billion). The shamefaced lottery firm shattered the 302 winners’ dreams by email an hour and a half later.

“All won prizes but not billions of crowns,” Thomas Rorsig, spokesman for Danske Spil, said. “The correct winnings .. were typically 200, 300 or 400 crowns (around $35 to $70)”. Rorsig said most had taken the bad news on the chin, though a few were “very angry” and demanded their original prize. Danske Spil was considering whether to boost the payouts by way of compensation, he added. He said the mishap was caused by “human error” when employees at Danske Spil were preparing letters to winners of Eurojackpot, a game with a large payouts though nowhere near the billions announced. Nothing like it had ever happened at Danske Spil, he said, “and I hope it never does again.”

CNBC.com, 23/3/2012

The Student Loans Company in England is responsible for thousands of government-sponsored loans for students who are either entering higher education or already in the system every year. Due to a human rather than system failure, thousands of email addresses have been inadvertently released in to the public domain. This week, over 8,000 students who are due to begin university this academic year were sent email reminders to complete and submit their application forms for loans and grant payments. If they had begun their application but had not completed it online, then the email was sent by the SLC as a standard reminder. However, the SLC staff that were in control of this process inadvertently included an attachment that contained the emails of every recipient — which was then received by each of the 8,000 to-be students.

In a following statement, the Student Loans Company apologized for the error, stating:
“The information was sent in error and only included email addresses, no other personal student data was shared […] The integrity and security of student accounts and the protection of personal information is vital to us, and we apologise to all of the students involved.”
The agency has been in touch with all of the students involved in the blunder.

This kind of mistake fortunately only included the email addresses of the students, but it does serve as a reminder of how only one small human error can result in a serious data protection breach. One student contacted the BBC and said:“This is such a disgusting error in the security of students’ data. They can’t get away with it.” On occasion, many firms suffer security breaches due to human mistakes, system disruption or deliberate hacking by third parties. However, it is necessary to both train and remind staff within these organisations that one small mistake can have catastrophic consequences – not only for the individuals involved, but for the firm itself. The flow and exchange of data online is difficult to control. To someone who specializes in fraud aimed at students, that attachment, even though it only contains email addresses, can be considered a goldmine – putting the students involved at a higher risk of attempted fraud.

The Student Loans Company has often come under fire — especially at the time in which students begin a new academic year and loans faces constant delays. In 2010 the government-owned agency was criticised for overcharging students on loans.

ZDNet, 22/3/2012

A forensic science firm which wrongly linked the DNA of a Devon man to the rape of a woman in Manchester has said the blunder was down to human error. The 19-year-old man was facing trial for raping a woman in October in Plant Hill Park, Blackley. The charges were dropped when it emerged a DNA sample had been contaminated at LGC Forensics in Teddington, west London. LCG said plastic trays had been incorrectly re-used in the laboratory. It said no other cases of contamination had been found.

The company said in a statement: “The forensic science regulator has agreed with LGC Forensics that the root cause of the contamination was human error in the incorrect re-use of plastic trays as part of the robotic DNA extraction process. “New processes have been introduced to prevent such an error happening again and 26,000 samples that have been processed since the robotics were introduced in March 2011 have been checked to ensure they had not been contaminated. “This checking is now complete and no other cases of contamination have been found.” It has previously said it deeply regretted the contamination.

Greater Manchester Police said the man accused of rape had told them he had never been to Manchester, but that LCG Forensics was “absolutely adamant” that was not the case. Police then charged the man with Crown Prosecution Service support. GMP Assistant Chief Constable Steve Heywood said it was “a tragic but isolated incident”. Philippa Jeffries, the solicitor for the man involved in the case, has called for a public inquiry and said her client was considering legal action.

BBC News, 21/3/2012

Human error caused the electrical fault that sparked a fire and shut down much of Perth’s rail network last week, Transport Minister Troy Buswell revealed today. A contractor working on the CityLink project incorrectly connected power cables, causing the electricity network to shortout, which led to the fire, Mr Buswell told Parliament. The incident occurred during the sinking of the Fremantle rail line.
About 30,000 commuters were stranded during morning peak-hour on Tuesday last week, with the Fremantle and Armadale-Midland lines unable to operate. Mr Buswell defended the Public Transport Authority’s response to the chaos, including sourcing 120 private buses. “We don’t keep buses around in sheds; it’s very difficult to respond in that circumstance,” he said. “It’s not a good enough outcome but it was human error not equipment error.” Mr Buswell said a review had identified issues, including that the electricity supply to the rail network is isolated to the CBD, which meant most of the network was affected despite distance. In an effort to avoid another widespread shutdown of the network, train turn around points would be created at Belmont and East Perth stations.

Syndey Morning Herald, 21/3/2012

These types of mistakes don’t happen often. But if your surgery is the one in 6,000 where it does, you’d probably wish some additional measures had been taken to avoid having a surgical sponge left inside you when it was over. “One in 6,000 is rare, but it’s one too many,” said Steve Campbell, chief medical officer for patient safety for Mayo Clinic Health System in Mankato. “The consequences of a sponge left behind can be huge.” In 2009, the Mayo Clinic in Rochester implemented new technology to avoid such mistakes. It’s a simple bar code reader, but the way it is used has the potential to cut down on human error dramatically. As of last week, that same technology is now being used in Mayo Clinic Health System in Mankato and Mayo Clinic Health System in New Prague.

Here’s how it works:
In surgeries and childbirth, a package of sponges will be used. The wrapped package comes with one bar code, which is scanned at the beginning of a procedure. When the procedure is complete, the sponges — each of which has an individual bar code — are scanned individually to make sure each is accounted for. They’re also counted manually as has always been the case. The reason for going to a bar-code scanner was simple: safety.

In the Minnesota Department of Health’s most recent annual report of so-called “adverse incidents,” Mayo Clinic Health System in Mankato had just one incident flagged. Campbell said this week that the incident involved what is known as “retention of a foreign object in a patient after surgery or other procedure.” That case, for which specific details are not releasable, involved a surgical sponge.
“We would hope going forward that we would never have another retained sponge,” Campbell said. “We’ve put in a system that reduces the chances of human error by one more step.”

Susan Pearson, an ear/nose/throat doctor who performs surgeries regularly, said she had reservations at first. “What concerned me the most was that it would take up a bunch of extra time when they’re scanning them,” she said. “And it really doesn’t.” Pearson said that use of the bar code scanning system mainly falls to the nurses. So far, she said, she’s seen it in action a handful of times. Nurses, who must count the sponges manually anyway, simply scan them as they’re counting them. The additional time required is negligible. Pearson said last year, across the state, there were 37 incidents of objects left in patients after surgery. The vast majority were sponges.

With surgeries and technology getting more complex, and with the doctor’s desire to get patients out of surgery as quickly as possible, the stress level during surgery can get high. Plus, the longer a patient is under anesthesia, the more complications can occur. There is plenty of incentive to get things done quickly. That’s why it’s good, Pearson said, to have that additional check in place to make sure an “adverse incident” doesn’t happen. And she’s been impressed with it so far. “It is pretty amazing,” she said. The bar code system is called SurgiCount, and since its debut in 2009 in Rochester, not one sponge has been left in a patient. It has scanned more than 1 million sponges. “This technology adds a layer of redundancy and takes out the element of human error,” Campbell said.

The plan is to roll it out throughout region in coming weeks. As for other tools used during surgery, the bar code system does not keep track of those. Although Campbell said research is being done to develop a system for that, too. And as for cost, the bar code system works out to cost about $2 per operation. “If we prevent one retained sponge, it pays for itself many times over,” he said.

The Free Press, 16/3/2012