Complexity, signal detection, and the application of ergonomics: reflections on a healthcare case study

Frontline nursing staff's perceptions of intravenous medication administration: the first step toward safer infusion processes-a qualitative study

OBJECTIVES

Intravenous medication errors continue to significantly impact patient safety and outcomes. This study sought to clarify the complexity and risks of the intravenous administration process.

DESIGN

A qualitative focus group interview study.

SETTING

Focused interviews were conducted using process mapping with frontline nurses responsible for medication administration in September 2020.

PARTICIPANTS

Front line experiened nurses from a Japanese tertiary teaching hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was to identify the mental models frontline nurses used during intravenous medication administration, which influence their interactions with patients, and secondarily, to examine the medication process gaps between the mental models nurses perceive and the actual defined medication administration process.

RESULTS

We found gaps between the perceived clinical administration process and the real process challenges with an emphasis on the importance of verifying to see if the drug was ordered for the patient immediately before its administration.

CONCLUSIONS

This novel and applied improvement approach can help nurses and managers better understand the process vulnerability of the infusion process and develop a deeper understanding of the administration steps useful for reliably improving the safety of intravenous medications.

A system safety approach to assessing risks in the sepsis treatment process

In healthcare, most accidents occur as a result of inadequate interactions between system components rather than component failures. In such cases traditional risk analysis methods are of limited use for analysing system safety, so methods such as Systems Theoretic Process Analysis (STPA) and the Functional Resonance Analysis Method (FRAM) have been developed. This study uses STPA to assess risks in the sepsis treatment process, discusses the potential value STPA adds and compares the results of STPA with the results of another study that used FRAM. The findings indicate that STPA and FRAM have different strengths which reflect the different scientific approaches behind these two methods. FRAM facilitates an in-depth understanding of a system, while STPA allows for more comprehensive risk analysis by identifying more risks, scenarios and safety recommendations. Nevertheless, it is reasonable to say that not only does STPA provide more comprehensive risk analysis; its terminology and philosophy are also closer to the current safety management applications employed in complex systems.

The complexity of human performance variability on watch standing task

The primary objective of this study was to examine the complexity of human temporal variability of topside roving watch task in naval operations concerning the reported times of ship status and to explore the potential presence of chaotic behavior and fractal properties of the reported log times. Topside rover reporting time intervals recorded in the deck logs of the USS Jason Dunham over the 2013-2015 period were analyzed to understand the underlying complexity of the watch standing task that is critical to the success of naval operations. The results on the 0-1 test, analysis of the largest Lyapunov exponents, as well the exploration of the fractal dimension and 1/f spectral analyses, showed that the fluctuation of standing watch time reports data exhibits chaotic and fractal system properties. The critical implications of the study findings for the human-centered design of complex systems were also discussed.

Drivers of intentions to use healthcare information systems among health and care professionals

Although investment in healthcare technology is rapidly increasing, the readiness to use emerging technologies among healthcare professionals is still low. The present study relies on an integrated model derived from the unified theory of acceptance and use of technology and the diffusion of innovation model to assess the factors that predicted healthcare professionals’ intentions to use healthcare information systems. Using a cross-sectional correlational design, 105 healthcare professionals (M age = 41.06, standard deviation = 9.18; 49% consultants and General Practitioners (GPs); 56.2% females) from hospitals in England completed online structured questionnaires. One-way analysis of variance showed that there were no differences in healthcare information systems usage intentions, unified theory of acceptance and use of technology and diffusion of innovation variables between consultants/GPs and non-medical staff (i.e. nurses and administration staff). Linear regression analysis demonstrated that the integrative model predicted 78.1 per cent (adjusted R2) in intentions to use healthcare information systems, and variables from both unified theory of acceptance and use of technology and the diffusion of innovation had significant effects. Moderated regression analysis further revealed that the interaction between voluntariness and effort expectancy, and voluntariness and social influence significantly predicted usage intentions on top of the main effects of the individual predictors. This poses direct implications for both practice and theory in this field. Future research should consider the predictive validity of integrative theoretical models of technology acceptance and utilization in healthcare settings.

Participatory design of probability-based decision support tools for in-hospital nurses

Objective

To describe nurses' preferences for the design of a probability-based clinical decision support (PB-CDS) tool for in-hospital clinical deterioration.

Methods

A convenience sample of bedside nurses, charge nurses, and rapid response nurses (n = 20) from adult and pediatric hospitals completed participatory design sessions with researchers in a simulation laboratory to elicit preferred design considerations for a PB-CDS tool. Following theme-based content analysis, we shared findings with user interface designers and created a low-fidelity prototype.

Results

Three major themes and several considerations for design elements of a PB-CDS tool surfaced from end users. Themes focused on "painting a picture" of the patient condition over time, promoting empowerment, and aligning probability information with what a nurse already believes about the patient. The most notable design element consideration included visualizing a temporal trend of the predicted probability of the outcome along with user-selected overlapping depictions of vital signs, laboratory values, and outcome-related treatments and interventions. Participants expressed that the prototype adequately operationalized requests from the design sessions.

Conclusions

Participatory design served as a valuable method in taking the first step toward developing PB-CDS tools for nurses. This information about preferred design elements of tools that support, rather than interrupt, nurses' cognitive workflows can benefit future studies in this field as well as nurses' practice.

A Qualitative Exploration of Nurses' Information-Gathering Behaviors Prior to Decision Support Tool Design

BACKGROUND

Large and readily-available clinical datasets combined with improved computational resources have permitted the exploration of many new research and clinical questions. Predictive analytics, especially for adverse events, has surfaced as one promising application of big data, and although statistical results can be highly accurate, little is known about how nurses perceive this new information and how they might act upon it.

OBJECTIVES

Within the context of recognizing patients at risk for cardiopulmonary arrest, this study explored the possibility of incorporating predictive analytics into clinical workflows by identifying nurses' current information gathering activities and perceptions of probability-related terms.

METHODS

We used a qualitative description approach for data collection and analysis in order to understand participants' information gathering behaviors and term perceptions in their own words. We conducted one-on-one interviews and a focus group with a total of 10 direct care bedside nurses and 8 charge nurses.

RESULTS

Participants collected information from many sources that we categorized as: Patient, Other People, and Technology. The process by which they gathered information was conducted in an inconsistent order and differed by role. Major themes comprised: (a) attempts to find information from additional sources during uncertainty, (b) always being prepared for the worst-case scenario, and (c) the desire to review more detailed predictions. Use of the words probability, risk, and uncertainty were inconsistent.

CONCLUSIONS

In an effort to successfully incorporate predictive analytics into clinical workflows, we have described nurses' perceived work practices for gathering information related to clinical deterioration and nurses' beliefs related to probability-based information. Findings from our study could guide design and implementation efforts of predictive analytics in the clinical arena.Jeffery AD, Kennedy B, Dietrich MS, Mion LC, Novak LL. A Qualitative Exploration of Nurses' Information-Gathering Behaviors Prior to Decision Support Tool Design. Appl Clin Inform 2017; 8: 763-778 https://doi.org/10.4338/ACI-2017-02-RA-0033.

Integrating Postoperative Feedback Into Workflow: Perceived Practices and Barriers

OBJECTIVE

Previous studies have found that both resident and staff surgeons highly value postoperative feedback; and that such feedback has high educational value. However, little is known about how to consistently deliver this feedback. Our aim was to understand how often surgical residents should receive feedback and what barriers are preventing this from occurring.

DESIGN

Surveys were distributed to resident and attending surgeons. Questions focused on the current frequency of postoperative feedback, desired frequency and methods of feedback, and perceived barriers. Quantitative data were analyzed with descriptive statistics, and text responses were examined using coding.

SETTING

University-based general surgery department at a Midwestern institution.

PARTICIPANTS

General surgery residents (n = 23) and attending surgeons (n = 22) participated in this study.

RESULTS

Residents reported receiving and staff reported giving feedback for procedure-specific performance after 25% versus 34% of cases, general technical feedback after 36% versus 32%, and nontechnical performance after 17% versus 18%. Both perceived procedure-specific and general technical feedback should be given more than 80% of the time, and nontechnical feedback should happen for nearly 60% of cases. Verbal feedback immediately after the operation was rated as best practice. Both parties identified time, conflicting responsibilities, lack of privacy, and discomfort with giving and receiving meaningful feedback as barriers.

CONCLUSIONS

Both resident and staff surgeons agree that postoperative feedback is given far less often than it should. Future work should study intraoperative and postoperative feedback to validate resident and attending surgeons' perceptions such that interventions to improve and facilitate this process can be developed.

Analysis 320 coal mine accidents using structural equation modeling with unsafe conditions of the rules and regulations as exogenous variables

Mining has been historically considered as a naturally high-risk industry worldwide. Deaths caused by coal mine accidents are more than the sum of all other accidents in China. Statistics of 320 coal mine accidents in Shandong province show that all accidents contain indicators of "unsafe conditions of the rules and regulations" with a frequency of 1590, accounting for 74.3% of the total frequency of 2140. "Unsafe behaviors of the operator" is another important contributory factor, which mainly includes "operator error" and "venturing into dangerous places." A systems analysis approach was applied by using structural equation modeling (SEM) to examine the interactions between the contributory factors of coal mine accidents. The analysis of results leads to three conclusions. (i) "Unsafe conditions of the rules and regulations," affect the "unsafe behaviors of the operator," "unsafe conditions of the equipment," and "unsafe conditions of the environment." (ii) The three influencing factors of coal mine accidents (with the frequency of effect relation in descending order) are "lack of safety education and training," "rules and regulations of safety production responsibility," and "rules and regulations of supervision and inspection." (iii) The three influenced factors (with the frequency in descending order) of coal mine accidents are "venturing into dangerous places," "poor workplace environment," and "operator error."

A systematic review of mixed methods research on human factors and ergonomics in health care

This systematic literature review provides information on the use of mixed methods research in human factors and ergonomics (HFE) research in health care. Using the PRISMA methodology, we searched four databases (PubMed, PsycInfo, Web of Science, and Engineering Village) for studies that met the following inclusion criteria: (1) field study in health care, (2) mixing of qualitative and quantitative data, (3) HFE issues, and (4) empirical evidence. Using an iterative and collaborative process supported by a structured data collection form, the six authors identified a total of 58 studies that primarily address HFE issues in health information technology (e.g., usability) and in the work of healthcare workers. About two-thirds of the mixed methods studies used the convergent parallel study design where quantitative and qualitative data were collected simultaneously. A variety of methods were used for collecting data, including interview, survey and observation. The most frequent combination involved interview for qualitative data and survey for quantitative data. The use of mixed methods in healthcare HFE research has increased over time. However, increasing attention should be paid to the formal literature on mixed methods research to enhance the depth and breadth of this research.

Complex socio-technical systems: Characterization and management guidelines

Although ergonomics has paid increasing attention to the perspective of complexity, methods for its operationalization are scarce. This study introduces a framework for the operationalization of the "attribute view" of complexity, which involves: (i) the delimitation of the socio-technical system (STS); (ii) the description of four complexity attributes, namely a large number of elements in dynamic interactions, a wide diversity of elements, unexpected variability, and resilience; (iii) the assessment of six management guidelines, namely design slack, give visibility to processes and outcomes, anticipate and monitor the impacts of small changes, monitor the gap between prescription and practice, encourage diversity of perspectives when making decisions, and create an environment that supports resilience; and (iv) the identification of leverage points for improving the STS design, based on both the analysis of relationships among the attributes and their classification as irreducible/manageable complexity, and liability/asset. The use of the framework is illustrated by the study of an emergency department of a University hospital. Data collection involved analysis of documents, observations of work at the front-line, interviews with employees, and the application of questionnaires.

Assessing the compatibility of the management of standardized procedures with the complexity of a sociotechnical system: case study of a control room in an oil refinery

Although the need for the management of complex socio-technical systems (STS) to be compatible with the nature of those systems is widely recognized, there are few guidelines on how to determine the actual extent of this compatibility. The purpose of this study is to assess how compatible the management of standardized procedures (SPs) is with the nature of a complex STS. To this end, a case study was made of a control room in an oil refinery, involving the following stages: (a) delimitation of the investigated STS; (b) description of the STS according to a set of characteristics of complex STS; (c) application of two types of questionnaires to thirty workers - one of them to assess their perceptions about the applicability of seven principles of SPs management in complex STS and the other to determine their perceptions about the actual use of these principles; and (d) a feedback meeting with workers to discuss the results of the assessment. The assessment is discussed in terms of its limitations, usefulness and ease of use of the data collection and analysis tools.

Improving multi-tasking ability through action videogames

The present study examined whether action videogames can improve multi-tasking in high workload environments. Two groups with no action videogame experience were pre-tested using the Multi-Attribute Task Battery (MATB). It consists of two primary tasks; tracking and fuel management, and two secondary tasks; systems monitoring and communication. One group served as a control group, while a second played action videogames a minimum of 5 h a week for 10 weeks. Both groups returned for a post-assessment on the MATB. We found the videogame treatment enhanced performance on secondary tasks, without interfering with the primary tasks. Our results demonstrate action videogames can increase people's ability to take on additional tasks by increasing attentional capacity.

Mapping out the emergency department disposition decision for high-acuity patients

STUDY OBJECTIVE

There are sparse data on how emergency health professionals make the important decision of emergency department (ED) patient admission or discharge, also known as the disposition decision. This study seeks to create a process map, a visual step-by-step diagram, and highlight error-prone areas for disposition decisions for high-acuity or nonambulatory ED patients.

METHODS

We conducted 6 focus groups at an academic tertiary care ED: residents, social workers and registered nurses, registered nurses only, attending physicians, patient safety committee members, and consensus group from the 5 preceding groups. We asked participants to create a disposition decision process map and identify error-prone areas. We audiotaped, transcribed, and analyzed the sessions for themes, using qualitative techniques.

RESULTS

Forty-two stakeholders with clinical experience from 1 to 30 years participated. We found 9 dominant themes (ordered according to prevalence): triage, ED location of patient assessment, monitoring, diagnosis, departmental busyness, clinical gestalt, response to treatment, social work involvement, and patient and family communication. Groups identified overarching themes such as risk stratification and administrative policy. One group included dynamic elements such as interactions with consultants and handover. Participants described the following contributors to disposition error: triage, diagnostic error, communication error, ED location of patient assessment, and ED crowding.

CONCLUSION

Participants endorsed triage, diagnostic error, communication error, ED location of patient assessment, and ED crowding as the most important contributors to ED disposition decisionmaking errors. Understanding these factors in clinical decisionmaking is fundamental to improving future ED patient safety.