A closed ‘pop‐off’ valve and patient safety incident: A human factors approach to understanding error
Why this work is in the frame
A frame that forgets how it found something cannot be audited. These are the routes that admitted this work.
Bibliographic record
Abstract
Abstract A 3‐month‐old, 1.4 kg, female domestic short hair cat was scheduled for ovariohysterectomy surgery during a final‐year veterinary student clinical rotation. Shortly after transfer to the operating room (OR) and connection to the anaesthetic machine, signs consistent with high gas pressure build up in the anaesthetic breathing system were observed. Because a clear view of the anaesthetic machine was obscured, the cat was immediately disconnected from the breathing system and transferred to a different anaesthetic machine. Inspection of the OR anaesthetic machine revealed that the adjustable pressure limiting (APL) (‘pop‐off') valve was closed, despite completion of a machine checkout procedure at the start of the day. The valve was opened, the cat returned to the OR, and surgery completed. Recovery was uneventful. Investigation of the incident revealed several contributing factors leading to the APL valve being left closed.
Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it