Accurate fault root cause diagnosis is essential for ensuring stable industrial production. Traditional methods, which typically rely on the entire time series and overlook critical local features, can lead to biased ...Accurate fault root cause diagnosis is essential for ensuring stable industrial production. Traditional methods, which typically rely on the entire time series and overlook critical local features, can lead to biased inferences about causal relationships, thus hindering the accurate identification of root cause variables. This study proposed a shapelet-based state evolution graph for fault root cause diagnosis (SEG-RCD), which enables causal inference through the analysis of the important local features. First, the regularized autoencoder and fault contribution plot are used to identify the fault onset time and candidate root cause variables, respectively. Then, the most representative shapelets were extracted to construct a state evolution graph. Finally, the propagation path was extracted based on fault unit shapelets to pinpoint the fault root cause variable. The SEG-RCD can reduce the interference of noncausal information, enhancing the accuracy and interpretability of fault root cause diagnosis. The superiority of the proposed SEG-RCD was verified through experiments on a simulated penicillin fermentation process and an actual one.展开更多
Americans have always been proud of their democratic system. Since the end of World War Ⅱ, the United States has even used its democratic system as a template to “democratize” some other countries. However, in rece...Americans have always been proud of their democratic system. Since the end of World War Ⅱ, the United States has even used its democratic system as a template to “democratize” some other countries. However, in recent years, the domestic democratic chaos in the United States has intensified, causing widespread doubts about the American political system and its democratic model.展开更多
Root-cause identification plays a vital role in business decision making by providing effective future directions for the organizations.Aspect extraction and sentiment extraction plays a vital role in identifying the ...Root-cause identification plays a vital role in business decision making by providing effective future directions for the organizations.Aspect extraction and sentiment extraction plays a vital role in identifying the rootcauses.This paper proposes the Ensemble based temporal weighting and pareto ranking(ETP)model for Root-cause identification.Aspect extraction is performed based on rules and is followed by opinion identification using the proposed boosted ensemble model.The obtained aspects are validated and ranked using the proposed aspect weighing scheme.Pareto-rule based aspect selection is performed as the final selection mechanism and the results are presented for business decision making.Experiments were performed with the standard five product benchmark dataset.Performances on all five product reviews indicate the effective performance of the proposed model.Comparisons are performed using three standard state-of-the-art models and effectiveness is measured in terms of F-Measure and Detection rates.The results indicate improved performances exhibited by the proposed model with an increase in F-Measure levels at 1%–15%and detection rates at 4%–24%compared to the state-of-the-art models.展开更多
There are 36 counties affirmed to be aid-poverty-development county in the early 21st century, which distribute around the circumferential mountain of Sichuan Basin, According to the topographic features and the distr...There are 36 counties affirmed to be aid-poverty-development county in the early 21st century, which distribute around the circumferential mountain of Sichuan Basin, According to the topographic features and the distribution of nationality, these aid-poverty-development counties can be classified into 4 depressed-regions. Study shows that regional poverty performance of 4 depressed-regions not only has many commons in the field of regional economic structure and industry structure, which is far behind the average development performance of Sichuan in the field of economic sum per capita such as GDP, farmer net income per capita as well as retail scale consumer goods, it is also quite different related to infrastructure and social development within 4 depressed-regions. Regional Poverty is chronically resulted in interaction of the multi-factors. Natural condition constraint is the basic factor contributed to regional poverty, policy influences play key role, the poor culture is inherent factor to regional poverty and the marginal locations play important role.展开更多
Modern industrial systems are usually in large scale,consisting of massive components and variables that form a complex system topology.Owing to the interconnections among devices,a fault may occur and propagate to ex...Modern industrial systems are usually in large scale,consisting of massive components and variables that form a complex system topology.Owing to the interconnections among devices,a fault may occur and propagate to exert widespread influences and lead to a variety of alarms.Obtaining the root causes of alarms is beneficial to the decision supports in making corrective alarm responses.Existing data-driven methods for alarm root cause analysis detect causal relations among alarms mainly based on historical alarm event data.To improve the accuracy,this paper proposes a causal fusion inference method for industrial alarm root cause analysis based on process topology and alarm events.A Granger causality inference method considering process topology is exploited to find out the causal relations among alarms.The topological nodes are used as the inputs of the model,and the alarm causal adjacency matrix between alarm variables is obtained by calculating the likelihood of the topological Hawkes process.The root cause is then obtained from the directed acyclic graph(DAG)among alarm variables.The effectiveness of the proposed method is verified by simulations based on both a numerical example and the Tennessee Eastman process(TEP)model.展开更多
A distributed information network with complex network structure always has a challenge of locating fault root causes.In this paper,we propose a novel root cause analysis(RCA)method by random walk on the weighted faul...A distributed information network with complex network structure always has a challenge of locating fault root causes.In this paper,we propose a novel root cause analysis(RCA)method by random walk on the weighted fault propagation graph.Different from other RCA methods,it mines effective features information related to root causes from offline alarms.Combined with the information,online alarms and graph relationship of network structure are used to construct a weighted graph.Thus,this approach does not require operational experience and can be widely applied in different distributed networks.The proposed method can be used in multiple fault location cases.The experiment results show the proposed approach achieves much better performance with 6%higher precision at least for root fault location,compared with three baseline methods.Besides,we explain how the optimal parameter’s value in the random walk algorithm influences RCA results.展开更多
The paper discusses the framework for a risk-informed root cause analysis process.Such process enables scaling of the analysis performed based on the risk associated with the undesired event or condition,thereby creat...The paper discusses the framework for a risk-informed root cause analysis process.Such process enables scaling of the analysis performed based on the risk associated with the undesired event or condition,thereby creating tiers of analysis where the greater the risk,the more sophisticated the analysis.In a risk-informed root cause analysis process,a situation is normally not analyzed at a level less than what actually occurred.However,a situation may be investigated as though the consequence were greater than actually happened,especially if only slight differences in circumstances could result in a significantly higher consequence.While operational events or safety issues are normally expected to result only with negligible or marginal actual consequences,many of those would actually have certain potential to develop or propagate into catastrophic events.This potential can be expressed qualitatively or quantitatively.Risk-informing of root cause analysis relies on mapping the event or safety issue into a risk matrix which,traditionally,is a two-dimensional probability-consequence matrix.A new concept employed in the risk matrix for root cause analysis is that,while the probability reflects the observed or expected range of values(retaining,thus,its“traditional”meaning),the consequence reflects not only the observed or materialized impact(such as failure of equipment)but,also,its potential to propagate or develop into highly undesirable final state.The paper presents main elements of risk-informed root cause analysis process and discusses qualitative and quantitative aspects and approaches to determination of risk significance of operational events or safety issues.展开更多
Based on the translated version of“The Root Cause of Poverty”by Rutger Bregman on the Ted speech online platform,this research analyzes the application of direct borrowing,imitative translation and creative translat...Based on the translated version of“The Root Cause of Poverty”by Rutger Bregman on the Ted speech online platform,this research analyzes the application of direct borrowing,imitative translation and creative translation in English-Chinese translation.First,we believe the direct borrowing of a ready-made version is most ideal as it reveals the common ground both languages share when translating a source text.Next,it is preferable to imitate an already existing expression as similarity is reader-friendly.However,it is sometimes necessary to adopt creative translation to preserve differences to ensure that the meaning of the original language is accurately transmitted.展开更多
This paper is mainly written to explore how cultural differences and clashes between America and China give rise to mother-daughter discords and conflicts. The paper was conducted based on the definition of culture in...This paper is mainly written to explore how cultural differences and clashes between America and China give rise to mother-daughter discords and conflicts. The paper was conducted based on the definition of culture in order to make clear of cultural conflicts. It is written to analyze the two groups of women immigrants unavoidably encountering the clash between their ancestral culture—Chinese culture and the dominant culture--American culture. Furthermore, the paper demonstrates that the mothers' Chinese roots are the root cause of misunderstandings and conflicts between their American-born daughters and themselves.Besides, the writer analyzes that different standpoints towards education value between mothers and American- born daughters cause their misunderstanding and conflicts. The conclusion is that the diversities between Chinese culture and American culture are the root cause for the mother-daughter discords and conflicts.展开更多
In the production industry, safety is the focus object, especially in the metallurgical industry where safety accidents are more frequent. Enterprises develop steadily in the market, safety is the unshakable foundatio...In the production industry, safety is the focus object, especially in the metallurgical industry where safety accidents are more frequent. Enterprises develop steadily in the market, safety is the unshakable foundation, but also the production cornerstone to ensure industry competition. In the field of metallurgy, the production process is extremely complex, which is easy to cause explosion and burning accidents in the production process. At the same time, in the current mechanical automatic production, it is also easy to produce mechanical safety accidents. The reason is mainly caused by improper safety management. Therefore, this paper focuses on the analysis of frequent metallurgical safety production accidents, and constantly with the management concept of safety production, targeted research strategies to reduce safety accidents, and then provide reference for safe production in the metallurgical industry.展开更多
A new idea was proposed to find out the stability and root location of multi-dimensional linear time invariant discrete system (LTIDS) for real coefficient polynomials. For determining stability the sign criterion is ...A new idea was proposed to find out the stability and root location of multi-dimensional linear time invariant discrete system (LTIDS) for real coefficient polynomials. For determining stability the sign criterion is synthesized from the Jury’s method for stability which is derived from the characteristic polynomial coefficients of the discrete system. The number of roots lying inside or outside the unit circle and hence on the unit circle is directly determined from the proposed single modified Jury tabulation and the sign criterion. The proposed scheme is simple and the examples are given to bring out the merits of the proposed scheme which is also applicable for the singular and non-singular cases.展开更多
Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shou...Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shoulder. Tosh et al. (2011), who investigated and published the principal report discussing this bacterial outbreak, conclude that its most likely cause was the improper reprocessing of certain reusable, physically-complex, heat-stable arthroscopic instruments used during these arthroscopic procedures. These reusable instruments reportedly remained contaminated with remnant tissue, despite diligent efforts by the hospital to clean their internal structures. This retained bioburden presumably shielded the outbreak’s strain of embedded P. aeruginosa from contact with the pressurized steam, reportedly resulting in ineffective sterilization of these arthroscopic instruments and bacterial transmission. Objectives: First, to clarify which specific sterilization methods, in addition to steam sterilization, Methodist Hospital employed to process its reusable arthroscopic instrumentation at the time of its outbreak, in 2009;second, to evaluate Tosh et al.’s (2011) conclusion that ineffective steam sterilization due to inadequate cleaning was the most likely cause of this hospital’s outbreak;third, to consider whether any other hitherto unrecognized factors could have plausibly contributed to this outbreak;and, fourth, to assess whether any additional recommendations might be warranted to prevent disease transmission following arthroscopic procedures. Methods: The medical literature was reviewed;some of the principles of quality assurance, engineering and a root-cause analysis were employed;and Tosh et al.’s (2011) findings and conclusions were reviewed and compared with those of other published reports that evaluated the risk of disease transmission associated with the steam sterilization of physically-complex, heat-stable, soiled surgical instruments. Results and Conclusion: Reports documenting outbreaks of P. aeruginosa or another vegetative bacterium associated with the steam sterilization of inadequately cleaned surgical or arthroscopic instruments are scant. This finding—coupled with a number of published studies demonstrating the effective steam sterilization of complex instruments contaminated with vegetative bacteria mixed with organic debris, or, in one published series of tests, with resistant bacterial endospores coated with hydraulic fluid—raises for discussion whether Methodist Hospital’s outbreak might have been due to one or more factors other than, or in addition to, that which Tosh et al. (2011) conclude was its most likely cause. An example of such a factor not ruled out by Tosh et al. (2011) findings would be the re-contamination of the implicated arthroscopic instruments after sterilization. The specific methods that Methodist Hospital employed at the time of its outbreak to sterilize some of its arthroscopic instrumentation remain unclear. A number of additional recommendations are provided to prevent disease transmission following arthroscopic procedures.展开更多
Objective:To identify the root causes of typical adverse drug events through the lens of patient experiences proposing novel strategies to mitigate preventable harm.Methods:A qualitative case study leveraging in-depth...Objective:To identify the root causes of typical adverse drug events through the lens of patient experiences proposing novel strategies to mitigate preventable harm.Methods:A qualitative case study leveraging in-depth interviews with patients and families,anchored by Interactive Patient Par ticipation Theory,to analyze 4 high-severity adverse drug events(ADE)cases.Cases were purposively sampled from 8 communities in China's National Adverse Event Monitor Center(2018-2023).Semi-structured interviews explored patient perspectives,with data analyzed via thematic coding and triangulation against clinical records.Results:Five interconnected themes emerged:(1)erosion of trust,(2)communication breakdowns,(3)information asymmetry,(4)environmental inadequacies,and(5)technological alienation.Notably,75% of participants had≤high school education,and 50% used≥7 medications daily,compounding ADE risks.Conclusions:We considered elements mentioned by theory,exploring trust,communication,information,and suppor t as the root causes.In addition,we added“adaptability to new technology”as an impor tant and necessary component.It is impor tant and necessary to analyze typical adverse drug events from the perspectives of patients.展开更多
故障根因分析旨在找到导致特定问题、故障或事件发生的原因,是多个领域中追踪溯源的重要支撑技术,但现有方法在效率、准确性和稳定性等方面仍不能满足故障根因分析任务的实际需求。对此,将贝叶斯网作为相关属性之间依赖关系表示和推理...故障根因分析旨在找到导致特定问题、故障或事件发生的原因,是多个领域中追踪溯源的重要支撑技术,但现有方法在效率、准确性和稳定性等方面仍不能满足故障根因分析任务的实际需求。对此,将贝叶斯网作为相关属性之间依赖关系表示和推理的知识框架,提出基于贝叶斯网的故障根因分析方法。首先,针对高维数据和稀疏样本带来的挑战,提出基于向量量化自编码器的高维属性约简算法,并给出α-BIC评分准则,高效地学习根因贝叶斯网(Root Cause Bayesian Network,RCBN)。随后,基于贝叶斯网嵌入技术实现RCBN的高效推理,高效计算各原因条件下故障产生的可能性,进而使用因果模型中的Blame机制度量各原因对给定故障的贡献度,从而实现故障根因分析。在3个公共数据集和3个合成数据集上的实验结果表明,所提方法的平均检测准确性和效率明显优于对比方法,在CHILD数据集上精度提升了7%,运行时间快了60%。展开更多
基金support from the following foundations:the National Natural Science Foundation of China(62322309,62433004)Shanghai Science and Technology Innovation Action Plan(23S41900500)Shanghai Pilot Program for Basic Research(22TQ1400100-16).
文摘Accurate fault root cause diagnosis is essential for ensuring stable industrial production. Traditional methods, which typically rely on the entire time series and overlook critical local features, can lead to biased inferences about causal relationships, thus hindering the accurate identification of root cause variables. This study proposed a shapelet-based state evolution graph for fault root cause diagnosis (SEG-RCD), which enables causal inference through the analysis of the important local features. First, the regularized autoencoder and fault contribution plot are used to identify the fault onset time and candidate root cause variables, respectively. Then, the most representative shapelets were extracted to construct a state evolution graph. Finally, the propagation path was extracted based on fault unit shapelets to pinpoint the fault root cause variable. The SEG-RCD can reduce the interference of noncausal information, enhancing the accuracy and interpretability of fault root cause diagnosis. The superiority of the proposed SEG-RCD was verified through experiments on a simulated penicillin fermentation process and an actual one.
文摘Americans have always been proud of their democratic system. Since the end of World War Ⅱ, the United States has even used its democratic system as a template to “democratize” some other countries. However, in recent years, the domestic democratic chaos in the United States has intensified, causing widespread doubts about the American political system and its democratic model.
文摘Root-cause identification plays a vital role in business decision making by providing effective future directions for the organizations.Aspect extraction and sentiment extraction plays a vital role in identifying the rootcauses.This paper proposes the Ensemble based temporal weighting and pareto ranking(ETP)model for Root-cause identification.Aspect extraction is performed based on rules and is followed by opinion identification using the proposed boosted ensemble model.The obtained aspects are validated and ranked using the proposed aspect weighing scheme.Pareto-rule based aspect selection is performed as the final selection mechanism and the results are presented for business decision making.Experiments were performed with the standard five product benchmark dataset.Performances on all five product reviews indicate the effective performance of the proposed model.Comparisons are performed using three standard state-of-the-art models and effectiveness is measured in terms of F-Measure and Detection rates.The results indicate improved performances exhibited by the proposed model with an increase in F-Measure levels at 1%–15%and detection rates at 4%–24%compared to the state-of-the-art models.
基金Supported by Youth Funding of Sichuan Academy of Soclal Scienccs in 2003(YFSASS03-13)
文摘There are 36 counties affirmed to be aid-poverty-development county in the early 21st century, which distribute around the circumferential mountain of Sichuan Basin, According to the topographic features and the distribution of nationality, these aid-poverty-development counties can be classified into 4 depressed-regions. Study shows that regional poverty performance of 4 depressed-regions not only has many commons in the field of regional economic structure and industry structure, which is far behind the average development performance of Sichuan in the field of economic sum per capita such as GDP, farmer net income per capita as well as retail scale consumer goods, it is also quite different related to infrastructure and social development within 4 depressed-regions. Regional Poverty is chronically resulted in interaction of the multi-factors. Natural condition constraint is the basic factor contributed to regional poverty, policy influences play key role, the poor culture is inherent factor to regional poverty and the marginal locations play important role.
基金supported by the National Natural Science Foundation of China(Nos.61903345 and 61973287)。
文摘Modern industrial systems are usually in large scale,consisting of massive components and variables that form a complex system topology.Owing to the interconnections among devices,a fault may occur and propagate to exert widespread influences and lead to a variety of alarms.Obtaining the root causes of alarms is beneficial to the decision supports in making corrective alarm responses.Existing data-driven methods for alarm root cause analysis detect causal relations among alarms mainly based on historical alarm event data.To improve the accuracy,this paper proposes a causal fusion inference method for industrial alarm root cause analysis based on process topology and alarm events.A Granger causality inference method considering process topology is exploited to find out the causal relations among alarms.The topological nodes are used as the inputs of the model,and the alarm causal adjacency matrix between alarm variables is obtained by calculating the likelihood of the topological Hawkes process.The root cause is then obtained from the directed acyclic graph(DAG)among alarm variables.The effectiveness of the proposed method is verified by simulations based on both a numerical example and the Tennessee Eastman process(TEP)model.
基金supported by ZTE Industry-University-Institute Cooperation Funds under Grant No.HC-CN-20201120009。
文摘A distributed information network with complex network structure always has a challenge of locating fault root causes.In this paper,we propose a novel root cause analysis(RCA)method by random walk on the weighted fault propagation graph.Different from other RCA methods,it mines effective features information related to root causes from offline alarms.Combined with the information,online alarms and graph relationship of network structure are used to construct a weighted graph.Thus,this approach does not require operational experience and can be widely applied in different distributed networks.The proposed method can be used in multiple fault location cases.The experiment results show the proposed approach achieves much better performance with 6%higher precision at least for root fault location,compared with three baseline methods.Besides,we explain how the optimal parameter’s value in the random walk algorithm influences RCA results.
文摘The paper discusses the framework for a risk-informed root cause analysis process.Such process enables scaling of the analysis performed based on the risk associated with the undesired event or condition,thereby creating tiers of analysis where the greater the risk,the more sophisticated the analysis.In a risk-informed root cause analysis process,a situation is normally not analyzed at a level less than what actually occurred.However,a situation may be investigated as though the consequence were greater than actually happened,especially if only slight differences in circumstances could result in a significantly higher consequence.While operational events or safety issues are normally expected to result only with negligible or marginal actual consequences,many of those would actually have certain potential to develop or propagate into catastrophic events.This potential can be expressed qualitatively or quantitatively.Risk-informing of root cause analysis relies on mapping the event or safety issue into a risk matrix which,traditionally,is a two-dimensional probability-consequence matrix.A new concept employed in the risk matrix for root cause analysis is that,while the probability reflects the observed or expected range of values(retaining,thus,its“traditional”meaning),the consequence reflects not only the observed or materialized impact(such as failure of equipment)but,also,its potential to propagate or develop into highly undesirable final state.The paper presents main elements of risk-informed root cause analysis process and discusses qualitative and quantitative aspects and approaches to determination of risk significance of operational events or safety issues.
文摘Based on the translated version of“The Root Cause of Poverty”by Rutger Bregman on the Ted speech online platform,this research analyzes the application of direct borrowing,imitative translation and creative translation in English-Chinese translation.First,we believe the direct borrowing of a ready-made version is most ideal as it reveals the common ground both languages share when translating a source text.Next,it is preferable to imitate an already existing expression as similarity is reader-friendly.However,it is sometimes necessary to adopt creative translation to preserve differences to ensure that the meaning of the original language is accurately transmitted.
文摘This paper is mainly written to explore how cultural differences and clashes between America and China give rise to mother-daughter discords and conflicts. The paper was conducted based on the definition of culture in order to make clear of cultural conflicts. It is written to analyze the two groups of women immigrants unavoidably encountering the clash between their ancestral culture—Chinese culture and the dominant culture--American culture. Furthermore, the paper demonstrates that the mothers' Chinese roots are the root cause of misunderstandings and conflicts between their American-born daughters and themselves.Besides, the writer analyzes that different standpoints towards education value between mothers and American- born daughters cause their misunderstanding and conflicts. The conclusion is that the diversities between Chinese culture and American culture are the root cause for the mother-daughter discords and conflicts.
文摘In the production industry, safety is the focus object, especially in the metallurgical industry where safety accidents are more frequent. Enterprises develop steadily in the market, safety is the unshakable foundation, but also the production cornerstone to ensure industry competition. In the field of metallurgy, the production process is extremely complex, which is easy to cause explosion and burning accidents in the production process. At the same time, in the current mechanical automatic production, it is also easy to produce mechanical safety accidents. The reason is mainly caused by improper safety management. Therefore, this paper focuses on the analysis of frequent metallurgical safety production accidents, and constantly with the management concept of safety production, targeted research strategies to reduce safety accidents, and then provide reference for safe production in the metallurgical industry.
文摘A new idea was proposed to find out the stability and root location of multi-dimensional linear time invariant discrete system (LTIDS) for real coefficient polynomials. For determining stability the sign criterion is synthesized from the Jury’s method for stability which is derived from the characteristic polynomial coefficients of the discrete system. The number of roots lying inside or outside the unit circle and hence on the unit circle is directly determined from the proposed single modified Jury tabulation and the sign criterion. The proposed scheme is simple and the examples are given to bring out the merits of the proposed scheme which is also applicable for the singular and non-singular cases.
文摘Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shoulder. Tosh et al. (2011), who investigated and published the principal report discussing this bacterial outbreak, conclude that its most likely cause was the improper reprocessing of certain reusable, physically-complex, heat-stable arthroscopic instruments used during these arthroscopic procedures. These reusable instruments reportedly remained contaminated with remnant tissue, despite diligent efforts by the hospital to clean their internal structures. This retained bioburden presumably shielded the outbreak’s strain of embedded P. aeruginosa from contact with the pressurized steam, reportedly resulting in ineffective sterilization of these arthroscopic instruments and bacterial transmission. Objectives: First, to clarify which specific sterilization methods, in addition to steam sterilization, Methodist Hospital employed to process its reusable arthroscopic instrumentation at the time of its outbreak, in 2009;second, to evaluate Tosh et al.’s (2011) conclusion that ineffective steam sterilization due to inadequate cleaning was the most likely cause of this hospital’s outbreak;third, to consider whether any other hitherto unrecognized factors could have plausibly contributed to this outbreak;and, fourth, to assess whether any additional recommendations might be warranted to prevent disease transmission following arthroscopic procedures. Methods: The medical literature was reviewed;some of the principles of quality assurance, engineering and a root-cause analysis were employed;and Tosh et al.’s (2011) findings and conclusions were reviewed and compared with those of other published reports that evaluated the risk of disease transmission associated with the steam sterilization of physically-complex, heat-stable, soiled surgical instruments. Results and Conclusion: Reports documenting outbreaks of P. aeruginosa or another vegetative bacterium associated with the steam sterilization of inadequately cleaned surgical or arthroscopic instruments are scant. This finding—coupled with a number of published studies demonstrating the effective steam sterilization of complex instruments contaminated with vegetative bacteria mixed with organic debris, or, in one published series of tests, with resistant bacterial endospores coated with hydraulic fluid—raises for discussion whether Methodist Hospital’s outbreak might have been due to one or more factors other than, or in addition to, that which Tosh et al. (2011) conclude was its most likely cause. An example of such a factor not ruled out by Tosh et al. (2011) findings would be the re-contamination of the implicated arthroscopic instruments after sterilization. The specific methods that Methodist Hospital employed at the time of its outbreak to sterilize some of its arthroscopic instrumentation remain unclear. A number of additional recommendations are provided to prevent disease transmission following arthroscopic procedures.
基金supported by the Science and Technology Fund Project of Guizhou Health Commission(gzwkj2025-163)。
文摘Objective:To identify the root causes of typical adverse drug events through the lens of patient experiences proposing novel strategies to mitigate preventable harm.Methods:A qualitative case study leveraging in-depth interviews with patients and families,anchored by Interactive Patient Par ticipation Theory,to analyze 4 high-severity adverse drug events(ADE)cases.Cases were purposively sampled from 8 communities in China's National Adverse Event Monitor Center(2018-2023).Semi-structured interviews explored patient perspectives,with data analyzed via thematic coding and triangulation against clinical records.Results:Five interconnected themes emerged:(1)erosion of trust,(2)communication breakdowns,(3)information asymmetry,(4)environmental inadequacies,and(5)technological alienation.Notably,75% of participants had≤high school education,and 50% used≥7 medications daily,compounding ADE risks.Conclusions:We considered elements mentioned by theory,exploring trust,communication,information,and suppor t as the root causes.In addition,we added“adaptability to new technology”as an impor tant and necessary component.It is impor tant and necessary to analyze typical adverse drug events from the perspectives of patients.
文摘故障根因分析旨在找到导致特定问题、故障或事件发生的原因,是多个领域中追踪溯源的重要支撑技术,但现有方法在效率、准确性和稳定性等方面仍不能满足故障根因分析任务的实际需求。对此,将贝叶斯网作为相关属性之间依赖关系表示和推理的知识框架,提出基于贝叶斯网的故障根因分析方法。首先,针对高维数据和稀疏样本带来的挑战,提出基于向量量化自编码器的高维属性约简算法,并给出α-BIC评分准则,高效地学习根因贝叶斯网(Root Cause Bayesian Network,RCBN)。随后,基于贝叶斯网嵌入技术实现RCBN的高效推理,高效计算各原因条件下故障产生的可能性,进而使用因果模型中的Blame机制度量各原因对给定故障的贡献度,从而实现故障根因分析。在3个公共数据集和3个合成数据集上的实验结果表明,所提方法的平均检测准确性和效率明显优于对比方法,在CHILD数据集上精度提升了7%,运行时间快了60%。
