Near-Miss Detection in Nursing: Rules and Semantics

Part of the Annals of Information Systems book series (AOIS, volume 11)


Nursing science deals with human-to-human interaction delivering care service, showing several peculiarities compared with other life science domains. Semantic technologies can be applied to clinical nursing, where the risk management forms a particular application class. Bone marrow transplantation is a specific sub-domain in which nursing process lacks the quality of service’s predictability at run time, requiring error detection before their happening and semantic technologies complementing best nursing strategies. The intelligent mix of technologies delivering proactive feedback to human actors in a natural way is a challenge. We investigate on possible risk control measures in the above-said nursing, suggesting a combination of ICT and knowledge technologies.


Fuzzy Rule Tacit Knowledge Knowledge Technology Patient Room Event Chain 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Some of the achievements described in the chapter are inherited from Eureka co-funded projects HPPC/SEA, IKF, and FP7 project DOC@HAND. The work described in this chapter draws upon the contributions of many people, to whom the authors are indebted. Of course authors are solely responsible for any possible mistakes.


  1. 1.
    McCormick, K.: A concept analysis of uncertainty in illness. Journal of Nursing Scholarship 34(2) (2002) 127–131CrossRefGoogle Scholar
  2. 2.
    Hilton, B.A.: Perceptions of uncertainty: Its relevance to life-threatening and chronic illness. Critical Care Nurse 12(2) (1992) 70–73Google Scholar
  3. 3.
    Norville, R.: Hematopoietic stem cell transplantation. In: Tomlinson, D., Kline N. (eds.) Pediatric Oncology Nursing. Advanced Clinical Handbook, Springer (2005)Google Scholar
  4. 4.
    Garner, J.: Guideline for isolation precautions in hospitals. Hospital infection control practices advisory committee. Infect Control Hosp Epidemiol 17(1) (1996) 53–80; published erratum, Infect Control Hosp Epidemiol 17(4) (1996) 214CrossRefGoogle Scholar
  5. 5.
    Combination Chemotherapy and Bone Marrow Transplant in Treating Patients With Aplastic Anemia or Hematologic Cancer, National Cancer Institute (NCI) study, Sep. 2007Google Scholar
  6. 6.
    McCann, S. et al.: Outbreaks of infectious diseases in stem cell transplant units: A silent cause of death, Infectious diseases working party of EBMT. BoneMarrow Transplant 33 (2004) 519–529Google Scholar
  7. 7.
    Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients, Recom. of Am. Soc. of Blood and Marrow Transplantation, Accessed 18 Jan 2008
  8. 8.
    Garner, J., Favero, M.: Guidelines for hand washing and hospital environmental control. Springfield, VA, NTIS. United States Department of Commerce (1985)Google Scholar
  9. 9.
    Reason, J.: Actions not as planned: The price of automatization. In: Underwood, G., Stevens, R. (eds.) Aspects of Consciousness, Vol. 1. Academic Press, London (1979)Google Scholar
  10. 10.
    Norman, D.A.: Categorization of action slips. Psychological Review 88 (1981) 1–15CrossRefGoogle Scholar
  11. 11.
    Norman, D.A.: Things That Make Us Smart: Defending Human Attributes in the Age of the Machine. Addison-Wesley, Reading, MA, USA. ISBN 0-201-62695-0 (1993)Google Scholar
  12. 12.
    Hollnagel, E.: The phenotype of erroneous actions: Implications for HCI design. In: Weir, G.R.S., Alty, J.L. (eds.) Human-Computer Interaction and Complex Systems. Academic Press, London, ISBN 0-12-742660-4,  Chapter 4 (1991)Google Scholar
  13. 13.
    Rasmussen, J., Pedersen, O.M., Mancini, G., Carnino, A., Griffon, M., Gagnolet, P.: Classification system for reporting events involving human malfunctions. Technical Report Riso-M-2240, SIN-DOC(81)14, Riso National Laboratory, Roskilde, Denmark (1981)Google Scholar
  14. 14.
    Reason, J.: Generic error-modelling system (GEMS): A cognitive framework for locating human error forms. In: Rasmussen, J., Duncan, K., Leplat, J. (eds.) New Technology and Human Error. Wiley, London (1987)Google Scholar
  15. 15.
    Grant, T.J. 2001. Towards a Taxonomy of Erroneous Planning. Proceedings, 20th workshop of UK Planning & Scheduling Special Interest Group, University of Edinburgh, Scotland, 13–14 (December 2001), 1368–5708.Google Scholar
  16. 16.
    Eliade, M.: The Myth of the Eternal Return: Cosmos and History. Princeton University Press, Princeton, NJ (2005)Google Scholar
  17. 17.
    Reichenbach, H.: Philosophy of Space and Time. N.Y., Chapter 2.22 (1958)Google Scholar
  18. 18.
    Windelband, W.: Preludii. Filosofskie rechi i statji, SPB (1904)Google Scholar
  19. 19.
    Finkenzeller, K.: RFID Handbook 2nd Edition, Wiley, New York (2003)CrossRefGoogle Scholar
  20. 20.
    Haikin S.: Cognitive radio: Brain-empowered wireless communications, selected areas in communications. IEEE Journal 23(2) (Feb. 2005) 201–220Google Scholar
  21. 21.
    Ivanov, B., Ruser, H., Kellner, M.: Presence detection and person identification in smart homes. In: International Conference of Sensors and Systems 80–85. St. Petersburg Technical University, Russia (2002)Google Scholar
  22. 22.
    Raducanu, B., Subramanian, S., Markopoulos. P.: Human Presence detection by smart devices. In: Proceedings of Engineering of Intelligent Systems (EIS2004), Funchal, Island of Madeira, Portugal, 29 Feb-2 (March 2004)Google Scholar
  23. 23.
  24. 24.
  25. 25.
    Bobrov, A.: Polevye informazionnye vzaimodejstvija, Orel (2003)Google Scholar
  26. 26.
    Zadeh, L.: Fuzzy Sets, Information and Control (1965)Google Scholar
  27. 27.
    Baldwin, J.: Fuzzy logic and fuzzy reasoning. In: Mamdani, E., Gaines, B. (eds.) Fuzzy Reasoning and Its Applications. Academic Press, London (1981)Google Scholar
  28. 28.
    Kruse, R. et al.: Foundations of Fuzzy Systems, Wiley, Chichester (1994)Google Scholar
  29. 29.
    Halpern, J.: Reasoning about Uncertainty, MIT Press, Cambridge, MA (2003)Google Scholar
  30. 30.
    Endres-Niggemeyer, B.: Empirical Methods for Ontology Engineering in Bone Marrow Transplantation, in [ISKO Germany 6 Hamburg 1999] (2000) 335–341Google Scholar
  31. 31.
    Golbreich, C., Mercier, S.: Construction of the Dialysis and Transplantation Ontology, Advantages, Limits, and Questions About Protégé OWLGoogle Scholar
  32. 32.
    Henry, S, Mead, C.: Nursing classifications: Necessary but not sufficient for representing “what nurses do” for inclusion in computer-based patient records. Journal of the American Medical Informatics Association 4 (1997) 222–232CrossRefGoogle Scholar
  33. 33.
    Hardiker N, Rector A.: Modeling nursing terminology using the GRAIL representation language. Journal of the American Medical Informatics Association 5 (1998) 120–128CrossRefGoogle Scholar
  34. 34.
    Hardiker N.: Mediating between nursing intervention terminology systems. In: Bakken S. (ed.) A Medical Informatics Odyssey: Visions of the Future and Lessons from the Past. Hanley & Belfus, Philadelphia (2001) 239–243Google Scholar
  35. 35.
    Hardiker N.: Logical ontology for mediating between nursing intervention terminology systems. Methods of Information in Medicine 42 (2003) 265–270Google Scholar
  36. 36.
    Paik, W., Ham, E.: Learning to generate an ontology-based nursing care plan by virtual collaboration. Lecture Notes in Computer Science 3762 (2005) 1200–1204CrossRefGoogle Scholar
  37. 37.
    Hollnagel, E.: The phenotype of erroneous actions. International Journal of Man-Machine Studies 39 (1993) 1–32CrossRefGoogle Scholar
  38. 38.
    Houliston, B.: Integrating RFID Technology into a Drug Administration System, Health Care & Informatics Review Online (Dec. 2005)Google Scholar
  39. 39.
    Taneff, Y., Rice, J.: Hand cleansing device with monitoring capability. US Patent WO/2005/055793, 23-06-2005Google Scholar
  40. 40.
    Swoboda, S., et al.: Electronic monitoring & voice prompts improve hand hygiene and decrease nosocomial infections in intermediate care unit. Critical Care Medicine 2(32) (Feb 2004) 358–363CrossRefGoogle Scholar
  41. 41.
    Sammartino L., Simonov M., Soroldoni M., Tettamanzi A.: GAMUT – A system for customer modeling based on evolutionary algorithms. In: Whitley, L. D., et al. (eds.) Proceedings of the Genetic and Evolutionary Computation Conference (GECCO ’00), Las Vegas, Nevada, USA, July 8–12, Morgan Kaufmann, San Francisco, CA (2000)Google Scholar
  42. 42.
    Tettamanzi A.: A fuzzy frame-based knowledge representation formalism, In: LNCS: Lecture notes in Artificial Intelligence, Vol. 2955. Springer, Berlin (2006) 55–62Google Scholar
  43. 43.
    Gangemi A., Simonov M., Soroldoni M.: Ontology-driven natural language access to legacy and web services in the insurance domain. In: Abramowicz, W. (ed.) BIS 2004, Poznan, Wydawnictwo Akademii Ekonomicznej w Poznaniu (2005)Google Scholar
  44. 44.
    Gangemi A., Mika P.: Understanding the semantic web through descriptions and situations. In: Meersman, R., et al. (eds.) Proceedings of ODBASE03. Springer, Berlin (2003)Google Scholar
  45. 45.
    Gruninger M., Fox M.S.: “The Logic of Enterprise Modelling”, in Modelling and Methodologies for Enterprise Integration (1996) 140–157Google Scholar
  46. 46.
    Simonov M., et al.: Information, knowledge and interoperability for healthcare domain. In: Proceedings of AXMEDIS 2005, IEEE Computer Society Washington, USA (2005)Google Scholar
  47. 47.
    Rotter, M.: Chapter 87: Hand washing and hand disinfection. In: Mayhall CG. (ed.) Hospital Epidemiology and Infection Control. 2nd ed. Lippincott Williams and Wilkins, Baltimore, MD (1999) 1339–1355Google Scholar
  48. 48.
    Larson, E.: APIC guideline for handwashing & hand antisepsis in health care settings. Am J Infect Control 23(4) (1995) 251–269CrossRefGoogle Scholar
  49. 49.
    CDC. Guideline for prevention of nosocomial pneumonia. Respiratory Care39(12) (1994) 1191–1236Google Scholar
  50. 50.
    American Academy of Architecture for Health, Guidelines for Design and Construction of Hospital and Medical Facilities.American Institute of Architects Press, Washington, 1996–1967:58Google Scholar
  51. 51.
    Rutala, W.: APIC guideline for selection and use of disinfectants. American Journal of Infection Control 24(4) (1996) 313–342CrossRefGoogle Scholar
  52. 52.
    National Antimicrobial Information Network.: List of EPA registered products. At Accessed 18 Feb 2008
  53. 53.
    CDC.: Immunization of health care workers: Recommendations of the advisory committee on immunization practices (ACIP) and the hospital infection control practices advisory committee. MMWR 1997; 46 (No. RR-18) 1–42Google Scholar
  54. 54.
    Toscano, C., et al.: Bloodstream infections associated with needleless device use, bathing practices and home infusion. In: Proceedings of the 48th Annual Epidemic Intelligence Service Conference, April 19–23, Atlanta, GA (1999) 47Google Scholar
  55. 55.
    Do, A.N., et al.: Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. Journal of Infectious Diseases 179(2) (1999) 442–448CrossRefGoogle Scholar
  56. 56.
    Raad, I., et al.: Infection control of nosocomial respiratory viral disease in the immunocompromised host. American Journal of Medicine 102(3A) (1997) 48–52CrossRefGoogle Scholar
  57. 57.
    Patient safety applications of bar code and RFID technologies, White Paper, Zebra Technologies (2005)Google Scholar
  58. 58.
    Rice et al.: Hand cleaning device with monitoring capability. U.S. Patent 2005/0134465 A1, June 23 (2005)Google Scholar
  59. 59.
    Berger, S., Helmbold, A., Mosebach, H., Opel, B., Wieteck, P.: Wissenschaftliche Hintergründe ENP®. Baar-Ebenhausen (2008)Google Scholar
  60. 60.
    Bloch, I., Petrosino, A., Tettamanzi, A.: Fuzzy logic and applications, WILF 2005, vol. 3849 of Lecture Notes in Computer Science. Springer, Berlin (2006)Google Scholar
  61. 61.
    Scott, L., Rogers, A., Hwang, W.: Effects of critical care nurses’ work hours on vigilance and patients’ safety. American Journal of Critical Care 15 (2006) 30–37Google Scholar
  62. 62.
    Blackwell, T.: Sleepiness and Fatigue in the Medical Profession, Accessed 18 Feb 2008

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© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.ISMBTurinItaly
  2. 2.Facoltà di Medicina e chirurgiaUniversità di TorinoTurinItaly

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