A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety

Understanding the challenges of robotic-assisted surgery adoption: Perspectives from stakeholders and the general population on human-interaction, built environment, and training

This study aims to explore adoption barriers from three aspects critical to facilitating robotic-assisted-surgery (RAS) adoption: the human-robot-interaction, built-environment, and training. Guidelines for research and design are identified from these perspectives. This study consisted of three phases: 1) surveys to RAS stakeholders and a crowd-sourcing survey; 2) stakeholder focus groups; and 3) a workshop with subject-matter experts to prioritize future research for RAS. Barriers from the human-robot-interaction perspective include hesitancy among clinicians to trust automation and physical discomfort during prolonged RAS. Barriers impeding communication and workflow disruptions were identified considering the built-environment. Training barriers were exemplified by varying curriculums from formal (courses) to informal (peer training) for surgeons. Crowd-sourced survey results suggest socio-economic status plays a role in RAS perception. Design guidelines include: 1) improved ergonomics; 2) deliberate introduction of automation; 3) sufficient in-room storage for prospective operating rooms; and 4) the development of compact RAS devices for older/smaller rooms.

A Combined Telemedicine and Ambulatory Wound Care Team Intervention for Improving Cross-Sector Outpatient Chronic Wound Management: Protocol for the Mixed Methods TELE-AMBUS Research Project

BACKGROUND

There is a growing prevalence of nonhealing wounds and chronic diseases in society, and there is an associated need for wound management solutions that include the use of telemedicine. A broad spectrum of factors influences the planning and execution of interventions within telemedicine in chronic wound management, spanning organizations, technologies, and individuals, including professionals and patients. The Telemedicine and Ambulatory Wound Care Team (TELE-AMBUS) project applies a whole-system research approach to account for this spectrum of factors.

OBJECTIVE

The primary objective of this study was to explore and analyze the implementation and consequences of an outpatient wound management model, comprising 2 interconnected quality improvement interventions (ie, telemedicine and ambulatory wound care team) aimed at older and vulnerable patients with chronic wounds, across the specialist and primary health care sectors. Embedded in this objective is the aim to improve the competence levels of health care providers and, consequently, the service quality of outpatient wound management across specialist and primary health care services.

METHODS

This project examines the implementation and consequences of an outpatient wound management model through a combined process and economic evaluation research strategy. A sociotechnical system theory approach and multiple work package design support the examination. The project uses observations, conversations, interviews, and economic assessments to gather rich, in-depth insights and understanding on why and how the new wound management model contributes to a change or not compared with the traditional treatment model.

RESULTS

The project has been funded from 2021 to 2025. Baseline interviews have been conducted since April 2022 and concluded in January 2024. Fieldwork, including nonparticipant observations, semistructured interviews, and informal conversations, has been conducted since November 2022 and is expected to conclude in March 2025. In parallel and as part of the cost-effectiveness analyses, time usage data on the outpatient and regular clinical models are being gathered during the fieldwork.

CONCLUSIONS

We applied a whole-system approach in multiple ways, that is, to design or inform our fieldwork and to explore, evaluate, and translate project findings into practice across services. To our knowledge, this approach has not been undertaken in telemedicine in chronic wound management literature and associated human factors and ergonomics research. Thus, our approach can produce both original and novel research and theoretical results internationally.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55502.

Proactive patient safety: enhancing hospital readiness through simulation-based clinical systems testing and healthcare failure mode and effect analysis

BACKGROUND

Recognizing and identifying latent safety threats (LSTs) before patient care commences is crucial, aiding leaders in ensuring hospital readiness and extending its impact beyond patient safety alone. This study evaluated the effectiveness of a combination of Simulation-based Clinical Systems Testing (SbCST) with Healthcare Failure Mode and Effect Analysis (HFMEA) with regard to mitigating LSTs within a newly constructed hospital.

METHODS

Three phases of the combined SbCST and HFMEA approach were implemented across all hospital settings. The scenarios tested system functionalities, team responses, and resource availability. The threats thus identified were categorized into system-related issues, human issues, and resource issues, after which they were prioritized and addressed using mitigation strategies. Reassessment confirmed the effectiveness of these strategies before hospital commissioning.

RESULTS

More than 76% of the LSTs were mitigated through the combined approach. System-related issues, such as nonfunctional communication devices and faulty elevators, were addressed by leadership. Human issues such as miscommunication and nonadherence to hospital policy led to improvements in interprofessional communication and teamwork. Resource issues, including missing equipment and risks of oxygen explosion, were addressed through procurement, maintenance, and staff training for equipment preparation.

CONCLUSION

The SbCST and HFMEA were highly effective with regard to proactively identifying and mitigating LSTs across all aspects of hospital preparedness. This systematic and comprehensive approach offers a valuable tool for enhancing patient safety in new healthcare facilities, thereby potentially setting a new standard for proactive hazard identification and risk management in the context of healthcare construction and commissioning.

Preliminary adaptation of the systems thinking for everyday work cue card set in a US healthcare system: a pragmatic and participatory co-design approach

INTRODUCTION

Healthcare is a highly complex adaptive system, requiring a systems approach to understand its behaviour better. We adapt the Systems Thinking for Everyday Work (STEW) cue cards, initially introduced as a systems approach tool in the UK, in a US healthcare system as part of a study investigating the feasibility of a systems thinking approach for front-line workers.

METHODS

The original STEW cards were adapted using consensus-building methods with front-line staff and safety leaders.

RESULTS

Each card was examined for relevance, applicability, language and aesthetics (colour, style, visual cues and size). Two sets of cards were created due to the recognition that systems thinking was relatively new in healthcare and that the successful use of the principles on the cards would need initial facilitation to ensure their effective application. Six principles were agreed on and are presented in the cards: Your System outlines the need to agree that problems belong to a system and that the system must be defined. Viewpoints ensure that multiple voices are heard within the discussion. Work Condition highlights the resources, constraints and barriers that exist in the system and contribute to the system's functions. Interactions ask participants to understand how parts of the system interact to perform the work. Performance guides users to understand how work can be performed daily. Finally, Understanding seeks to promote a just cultural environment of appreciating that people do what makes sense to them. The two final sets of cards were scored using a content validity survey, with a final score of 1.

CONCLUSIONS

The cards provide an easy-to-use guide to help users understand the system being studied, learn from problems encountered and understand the everyday work involved in providing excellent care. The cards offer a practical 'systems approach' for use within complex healthcare systems.

Knowledge mapping analysis of safety ergonomics: a bibliometric study

Although a significant attention, the field of safety ergonomics has not yet been systematically profiled based on recent studies. To fully understand the current research status, basis, hotspots, and development trends in the field, 533 documents from the Web of Science core database were used for knowledge mapping analysis by the bibliometric method. The study found that the USA is the top country in publications, and Tehran University is the institution with the highest number of publications. Ergonomics and Applied Economics are the authoritative safety ergonomics journals. Through co-occurrence and co-citation analysis, current safety ergonomics research is focussed on healthcare, product design, and occupational health and safety. The keyword timeline view indicates that the main research paths are occupational health and safety, and patient safety research. The analysis of burst keywords shows that safety ergonomics research in management, model design, and system design areas are research frontiers in the field.Practitioner summary: This paper presents a knowledge mapping of safety ergonomics research through bibliometric analysis. The research results show the research status, research hotspots, and research frontiers in the field of safety ergonomics, which provides a direction for other scholars to quickly understand the development of this field.

Factors influencing clinician and patient interaction with machine learning-based risk prediction models: a systematic review

Machine learning (ML)-based risk prediction models hold the potential to support the health-care setting in several ways; however, use of such models is scarce. We aimed to review health-care professional (HCP) and patient perceptions of ML risk prediction models in published literature, to inform future risk prediction model development. Following database and citation searches, we identified 41 articles suitable for inclusion. Article quality varied with qualitative studies performing strongest. Overall, perceptions of ML risk prediction models were positive. HCPs and patients considered that models have the potential to add benefit in the health-care setting. However, reservations remain; for example, concerns regarding data quality for model development and fears of unintended consequences following ML model use. We identified that public views regarding these models might be more negative than HCPs and that concerns (eg, extra demands on workload) were not always borne out in practice. Conclusions are tempered by the low number of patient and public studies, the absence of participant ethnic diversity, and variation in article quality. We identified gaps in knowledge (particularly views from under-represented groups) and optimum methods for model explanation and alerts, which require future research.

Automation in health care: the need for an ergonomics-based approach

Healthcare quality and efficiency challenges degrade outcomes and burden multiple stakeholders. Workforce shortage, burnout, and complexity of workflows necessitate effective support for patients and providers. There is interest in employing automation, or the use of 'computer[s] [to] carry out… functions that the human operator would normally perform', in health care to improve delivery of services. However, unique aspects of health care require analysis of workflows across several domains and an understanding of the ways work system factors interact to shape those workflows. Ergonomics has identified key work system issues relevant to effective automation in other industries. Understanding these issues in health care can direct opportunities for the effective use of automation in health care. This article illustrates work system considerations using two example workflows; discusses how those considerations may inform solution design, implementation, and use; and provides future directions to advance the essential role of ergonomics in healthcare automation.

Application of Participatory Ergonomics to the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use

BACKGROUND

Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of this study was to evaluate the dissemination process and its impact on blood culture reduction.

METHODS

The PE approach emphasized three key principles (stakeholder participation, application of human factors and ergonomics knowledge and tools, and cross-site collaboration) with a six-step dissemination process. Data on interactions between sites and the coordinating team and site experiences with the dissemination process were collected using site diaries and semiannual surveys with local QI teams, respectively, and correlated with the site-specific change in blood culture rates.

RESULTS

Overall, participating sites were able to successfully implement the program and reduced their blood culture rates from 149.4 blood cultures per 1,000 patient-days/month before implementation to 100.5 blood cultures per 1,000 patient-days/month after implementation, corresponding to a 32.7% relative reduction (p < 0.001). Variations in the dissemination process, as well as in local interventions and implementation strategies, were observed across sites. Site-specific changes in blood culture rates were weakly negatively correlated with the number of preintervention interactions with the coordinating team (p = 0.057) but not correlated with their experiences with the six domains of the dissemination process or their interventions.

CONCLUSIONS

The authors applied a PE approach to disseminate a QI program for optimizing PICU blood culture use to a multisite collaborative. Working with local stakeholders, participating sites tailored their interventions and implementation processes and achieved the goal of reducing blood culture use.

The Standardization of the Emergency Department Response to Chemical, Biological, Radiological, and Nuclear (CBRN) Events: Human Factors/Ergonomics Approach

OBJECTIVE

To provide standardized recommendations for the emergency department (ED) response to chemical, biological, radiological, and nuclear (CBRN) events by combining the human factors/ergonomics method of hierarchical task analysis with the theoretical framework for Work as Imagined versus Work as Done.

METHODS

Document analyses were used to represent CBRN response operational procedures. Semi-structured interviews using scenario cards were carried out with 57 first receivers (ED staff) to represent CBRN practice at 2 acute hospitals in England.

RESULTS

Variability existed in general organizational responsibilities associated with the CBRN response. Variability was further evident in top level CBRN tasks and CBRN phases at both EDs. Operational procedures focused on tasks such as documentation, checking, and timing. CBRN practice focused on patient needs through assessment, treatment, and diagnosis.

CONCLUSION

The findings provide top-down and bottom-up insights to enhance the ED CBRN response through standardization. The standardized CBRN action card template embeds the choice approach to standardization. The standardized CBRN framework implements the streamlined categorization of CBRN phases. Work as Imagined versus Work as Done is a useful theoretical framework to unpack a complex sociotechnical system, and hierarchical task analysis is an effective system mapping tool in health care.

Systems, safety, and anaesthesia outside the operating room

An increasing number of patients are receiving sedation or anaesthesia in locations outside of the operating room. Compared with the operating room, anaesthesia providers working in a non-operating room anaesthesia (NORA) location report significantly lower perceived levels of safety, and higher levels of anxiety, stress, and workload. These results are likely to affect the well-being of staff in NORA locations and are clinically relevant in terms of patient safety.

Designing healthcare for human use: Human factors and practical considerations for the translational process

In recent years, the focus of implementation science (IS) shifted to emphasize the influence of contextual factors on intervention adaptations in clinical, community, and corporate settings. Each of these settings represent a unique work system with varying contexts that influence human capabilities, needs, and performance (otherwise known as "human factors"). The ease of human interaction with a work system or an intervention is imperative to IS outcomes, particularly adoption, implementation, and maintenance. Both scientific approaches consider the "big picture" when designing interventions for users and stakeholders to improve work and health outcomes. IS and human factors are therefore complementary in nature. In this paper, the authors will (1) provide perspective on the synergistic relationship between human factors and IS using two illustrative and applied cases and (2) outline practical considerations for human factors-based strategies to identify contextual factors that influence intervention adoption, implementation, and maintenance dimensions of the RE-AIM framework. This article expands on recent research that developed user- and human-centered design strategies for IS scientists to use. However, defining the complementary relationship between IS and human factors is a necessary and valuable step in maximizing the effectiveness of IS to transform healthcare. While IS can complement practitioners' identification of intervention adaptations, human interaction is a process in the work system often overlooked throughout implementation. Further work is needed to address the influence that organizational endorsement and trust have on intervention adaptations and their translation into the work system.

A cross-sector systematic review and synthesis of knowledge on telemedicine interventions in chronic wound management-Implications from a system perspective

Based on initially identified needs for further telemedicine (TM) and chronic wound management research, the objective of this article is twofold: to conduct a systematic review of existing knowledge on TM interventions in chronic wound management-including barriers and opportunities-across the specialist and primary care sectors, and to incorporate the review findings into a system framework that can be further developed and validated through empirical data. We conclude that there is a pressing need for broader and more comprehensive empirical explorations into quality improvement and integration of TM in chronic wound management, including using system frameworks that can capture cross-sector system perspectives and associated implications. Of practical consideration, we suggest that the design and execution of TM improvement interventions and associated research projects should be conducted in close cooperation with managers and practitioners knowledgeable about barriers and opportunities that can influence the implementation of important interventions within chronic wound management.

Prevalence, Prevention, and Treatment of Work-Related Musculoskeletal Disorders Among Microsurgeons

BACKGROUND

 While work related musculoskeletal disorders have been well recognized among all surgeons, and microsurgeons in particular; their prevention and treatment are presently unknown. Our study aims to define the impact of musculoskeletal ailments on microsurgeons and investigate trends in microsurgeon musculoskeletal injury treatment.

METHODS

 An electronic survey was sent to all members of the American Society of Reconstructive Microsurgery. The survey solicited surgeon demographics, microsurgical volume, equipment usage, history of musculoskeletal injury, impact of injury, and interventions / treatment modalities used to address / prevent these issues.

RESULTS

 Of the 883 microsurgeons surveyed, 203 responded (23% response rate). The average age was 45 years (IQR 39-52 years). Most microsurgeons were male (80.8%). Musculoskeletal injury or symptoms related to microsurgery were reported by 137 respondents (67.0%). Fifty surgeons (37.9%) reported that their musculoskeletal injury had adversely affected their practice. Formal medical intervention was sought by 53 respondents (26.1%), with 17 surgeons (8.4%) undergoing surgical intervention. Self-treated was used by 127 microsurgeons (62.6%) for musculoskeletal ailments. Preventative treatments such as strength training, stretching, yoga, massages, and diet were the most beneficial, each with utilization scores of 4 out of 5.

CONCLUSION

 A majority of microsurgeons experience musculoskeletal injury, and some even require surgery to treat their musculoskeletal pathology. Prophylactic practices such as strength training, stretching, yoga, massages, and diet maintenance, are the superior treatment for musculoskeletal injury. Microsurgeons should incorporate training routines in their lives as injury prophylaxis to improve their career longevity and patient care.

Patient engagement and prescription opioid use in perioperative pain management

OBJECTIVE

To examine (1) patient perceptions regarding their engagement and the engagement of their families in perioperative pain management, (2) demographic and clinical characteristics associated with perceived patient and family engagement, and (3) the association between perceived patient and family engagement and patient outcomes.

DESIGN

A prospective, observational study.

SETTING

The Personalized Pain Program (PPP) at the Johns Hopkins Hospital in Baltimore, Maryland.

PARTICIPANTS

Patients having more than one visit to the PPP.

INTERVENTIONS

n/a.

MAIN OUTCOME MEASURES

Since the inception of the PPP, patients were surveyed prior to each clinic visit to assess their pain severity and interference using the Brief Pain Inventory. Starting August 22, 2018, two additional questions were added to the survey to assess patient perceptions of their engagement and the engagement of their families in perioperative pain management. In addition, electronic medical records were reviewed to collect data on daily opioid consumption during the first and last PPP visits presurgery and post-surgery.

RESULTS

The final analysis included 511 survey responses from 155 patients. Perceived engagement of the patient in perioperative pain management improved over time (p < .001) and was significantly associated with reduction in prescription opioid consumption after surgery (coef = 12.7, SE = 5.8, p = .031).

CONCLUSIONS

Surgical patients and their family members should be actively engaged in perioperative pain management to improve prescription opioid use and the quality and safety of perioperative care.

Influence of Evidence-Based Design Strategies on Nurse Wellness

OBJECTIVES

The purpose of this study was to understand how specific evidence-based design strategies are related to aspects of nurse wellness.

BACKGROUND

Addressing burnout among the healthcare workforce is a system-level imperative. Nurses face continuous and dynamic physical and emotional demands in their role. Greater insight into the role of the physical environment can support efforts to promote nurse wellness.

METHODS

This exploratory qualitative study was conducted at new Parkland Hospital in Dallas, TX. We conducted five focus groups with nursing staff in July 2018. These sessions covered five topics related to nursing work in the facility which had been redesigned nearly 3 years earlier: (1) professional and social communication, (2) workflow and efficiency, (3) nurses' tasks and documentation, (4) ability to care for patients, and (5) nurses' overall health. We conducted a thematic analysis and first identified different aspects of wellness discussed by participants. Then, we examined how nurses related different design elements to different aspects of their wellness.

RESULTS

Participants included 63 nurses and nurse managers. They related environmental factors including facility size, break rooms, and decentralized workstations to social, emotional/spiritual, physical, intellectual, and occupational aspects of wellness.

CONCLUSIONS

It is critical to inform and integrate nurses at all levels into planning, design, and activation of new healthcare environments in order to ensure the well-being of nurses and, therefore, their ability to effectively support patients.

Closing the communication gap in neonatal inter-hospital transfer: a neonatal referral form for resource-limited settings - a modified e-Delphi-consensus study

Background: Standardised neonatal referral forms (NRFs) facilitate effective communication between healthcare providers and ensure continuity of care between facilities, which are essential for patient safety. We sought to determine the essential data items, or core clinical information (CCI), that should be conveyed for neonatal inter-hospital transfer in resource-limited settings (Rounds 1 to 3) and to create an NRF suitable for our setting (Round 4).

Methods: We conducted an international, four-round, modified Delphi-consensus study. Round-1 was a literature and internet search to identify existing NRFs. In Round-2 and -3, participants were Rwandan clinicians and international paediatric healthcare practitioners who had worked in Rwanda in the five years before the study. These participants evaluated the draft items and proposed additional items to be included in an NRF. Round-4 focused on creating the NRF and used five focus groups of Rwandan general practitioners at district hospitals.

Results: We identified 16 pre-existing NRFs containing 125 individual items. Of these, 91 items met the pre-defined consensus criteria for inclusion in Round-2. Only 33 items were present in more than 50% of the 16 NRFs, confirming the need for this consensus study. In Round-2, participants proposed 12 new items, six of which met the pre-defined consensus criteria. In Round-3, participants scored items for importance, and 57 items met the final consensus criteria. In Round-4, 29 general practitioners took part in five focus groups; a total of 16 modifications were utilised to finalise the NRF.

Conclusions: We generated a novel, robust, NRF that may be readily employed in resource-limited settings to communicate the essential clinical information to accompany a neonate requiring inter-hospital transfer.

Focused-Attention Meditation Improves Flow, Communication Skills, and Safety Attitudes of Surgeons

OBJECTIVE

Patient safety is a worldwide problem and a focus of academic research. Human factors and ergonomics (HFE) is an approach to improving healthcare work systems and processes. From the perspective of the cognitive ergonomics of HFE, the aim of this study is to improve the flow level, communication skills, and safety attitudes of surgeons through focused-attention meditation (FAM) training, thus helping to reduce adverse clinical events.

METHODS

In total, 140 surgeons were recruited from three hospitals in China and randomly divided into two groups (FAM group and control group). The FAM group received 8 weeks of FAM training, while the control group was on the waiting list and did not receive any interventions. Three scales (WOLF, LCSAS, and SAQ-C) were used to measure the data of three variables (flow, communication skills, and safety attitude), respectively, at two times, before and after the intervention (pre-test and post-test). The incidence of adverse events during the intervention was also collected for both groups.

RESULTS

The ANOVA results showed that all three variables had a significant main effect of time and significant interactions between time and group. The independent-sample T-test results showed that the incidence of adverse events during the intervention was significantly lower in the FAM group than in the control group.

CONCLUSIONS

The intervention of FAM could significantly improve surgeons' flow levels, communication skills, and safety attitudes, potentially helping to reduce adverse clinical events.

Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective

BACKGROUND

Hospitals in various countries such as the Netherlands investigate and analyse serious adverse events (SAEs) to learn from previous events and attempt to prevent recurrence. However, current methods for SAE analysis do not address the complexity of healthcare and investigations typically focus on single events on the hospital level. This hampers hospitals in their ambition to learn from SAEs. Integrating human factors thinking and using a holistic and more consistent method could improve learning from SAEs.

AIM

This study aims to develop a novel generic analysis method (GAM) to: (1) facilitate a holistic event analysis using a human factors perspective and (2) ease aggregate analysis of events across hospitals.

METHODS

Multiple steps of carefully evaluating, testing and continuously refining prototypes of the method were performed. Various Dutch stakeholders in the field of patient safety were involved in each step. Theoretical experts were consulted, and the prototype was pretested using information-rich SAE reports from Dutch hospitals. Expert panels, engaging quality and safety experts and medical specialists from various hospitals were consulted for face and content validity evaluation. User test sessions concluded the development of the method.

RESULTS

The final version of the GAM consists of a framework and affiliated questionnaire. GAM combines elements of three methods for SAE analysis currently practised by Dutch hospitals. It is structured according to the Systems Engineering Initiative for Patient Safety model, which incorporates a human factors perspective into the analysis. These eases aggregated analysis of SAEs across hospitals and helps to consider the complexity of healthcare work systems.

CONCLUSION

The GAM is a valuable new tool for hospitals to learn from SAEs. The method can facilitate a holistic aggregate analysis of SAEs across hospitals using a human factors perspective, and is now ready for further extensive testing.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Applying Intelligent Algorithms to Automate the Identification of Error Factors

OBJECTIVES

Medical errors are the manifestation of the defects occurring in medical processes. Extracting and identifying defects as medical error factors from these processes are an effective approach to prevent medical errors. However, it is a difficult and time-consuming task and requires an analyst with a professional medical background. The issues of identifying a method to extract medical error factors and reduce the extraction difficulty need to be resolved.

METHODS

In this research, a systematic methodology to extract and identify error factors in the medical administration process was proposed. The design of the error report, extraction of the error factors, and identification of the error factors were analyzed.

RESULTS

Based on 624 medical error cases across four medical institutes in both Japan and China, 19 error-related items and their levels were extracted. After which, they were closely related to 12 error factors. The relational model between the error-related items and error factors was established based on a genetic algorithm (GA)-back-propagation neural network (BPNN) model. Additionally, compared to GA-BPNN, BPNN, partial least squares regression and support vector regression, GA-BPNN exhibited a higher overall prediction accuracy, being able to promptly identify the error factors from the error-related items.

CONCLUSIONS

The combination of "error-related items, their different levels, and the GA-BPNN model" was proposed as an error-factor identification technology, which could automatically identify medical error factors.

Ergonomics Among Craniofacial Surgeons: A Survey of Work-Related Musculoskeletal Discomfort and Injury

INTRODUCTION

Surgical procedures with loupe magnification, headlights, and microscopes expose craniofacial surgeons to mechanical stress that can increase risk of long-term musculoskeletal pain and injury. Identifying the prevalence and cause of work-related musculoskeletal discomfort may guide preventative strategies to prolong well-being, job satisfaction, and greater duration of surgical careers.

METHODS

A 29-question online survey was distributed to the surgeon members of the American Cleft Palate-Craniofacial Association. Eight hundred seventy-three surveys were distributed, and the anonymous responses were recorded using Google forms.

RESULTS

One hundred ninety-six unique responses were recorded (22.5% response rate). A total of 64.2% reported experiencing musculoskeletal symptoms during their career, with neck, lower back, and shoulders being the most common problem areas. Multivariate analysis demonstrated surgical loupes (odds ratio 2.36, P = 0.03) and length of surgical practice >15 years (odds ratio 1.95, P = 0.04) were independently associated with greater odds of developing symptoms. Headlights (median pain = 3, P < 0.001), loupes (median pain = 3.5, P < 0.001), and operative microscope use (median pain = 2, P = 0.02) were all associated with higher pain while operating. A total of 52.5% respondents sought medical treatments, 50.5% were concerned musculoskeletal discomfort would affect their careers, 56.6% reported a colleague that required an operation, and 30.2% reported a colleague on temporary or permanent disability.

CONCLUSIONS

Craniofacial surgery often involves long procedures, use of surgical adjuncts, and ergonomically straining postures, which can lead to musculoskeletal discomfort and injury. This under-reported and important phenomenon merits candid conversation and active preventative strategies to prolong surgical careers, improve professional satisfaction, and maximize patient safety.

Physician Well-being 2.0: Where Are We and Where Are We Going?

Although awareness of the importance of physician well-being has increased in recent years, the research that defined this issue, identified the contributing factors, and provided evidence on effective individual and system-level solutions has been maturing for several decades. During this interval, the field has evolved through several phases, each influenced not only by an expanding research base but also by changes in the demographic characteristics of the physician workforce and the evolution of the health care delivery system. This perspective summarizes the historical phase of this journey (the "era of distress"), the current state (Well-being 1.0), and the early contours of the next phase based on recent research and the experience of vanguard institutions (Well-being 2.0). The key characteristics and mindset of each phase are summarized to provide context for the current state, to illustrate how the field has evolved, and to help organizations and leaders advance from Well-being 1.0 to Well-being 2.0 thinking. Now that many of the lessons of the Well-being 1.0 phase have been internalized, the profession, organizations, leaders, and individual physicians should act to accelerate the transition to Well-being 2.0.

The impact of power on health care team performance and patient safety: a review of the literature

Communication failure within health care teams is a major cause of patient harm across health care settings. Factors which contribute to communication failure include actual or perceived 'power'. Whilst a great deal of ergonomics research has focussed on teamwork in health care, the role of power in relation to measurable patient safety and performance outcomes remains relatively unknown. This article presents the findings from a review of the literature on power within multidisciplinary health care team settings. Following a systematic literature search, nineteen studies were evaluated in terms of research design, methods and analyses across the included studies. The main impacts resulting from power imbalances include negative effects on team collaboration, decision-making, communication and overall performance. Wider patient safety research, and more specifically the ergonomics discipline, is encouraged to address the complex interplay between power and teamwork in the health care sector.Practitioner Statement: We conducted a review of studies focussed on the influence of power on teamwork in health care. The findings show that power can have negative impacts on collaboration, decision-making, communication, and team performance. We conclude that power represents an important area for ergonomics, both in health care and other settings.Abbreviations: CRM: crew resource management; TEM: threat and error management; SNA: social network analysis; EAST: event analysis of systemic teamwork.

A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children's Intensive Care

BACKGROUND

Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas.

OBJECTIVE

This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs).

METHODS

We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents.

RESULTS

In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols.

CONCLUSIONS

Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.

Fatigue and the Female Nurse: A Narrative Review of the Current State of Research and Future Directions

Background: The female nurse exhibits a multitude of personal and environmental characteristics that renders this population especially prone to fatigue. The consequences of fatigue in nurses are widespread and impactful at the personal, organizational, and societal levels. These include high injury rates and burnout in the nurse and poor patient and organizational outcomes. Objective: This article discusses the implications of fatigue in female nurses, including the impacts of fatigue across multiple entities (e.g., worker, patient, organization). It also reviews the current state of the research, including recent work on nurse fatigue and work schedule characteristics, and key areas for future work that would help empirically establish approaches to counter the detrimental and widespread effects of fatigue. Method: A narrative literature review was conducted resulting from an analysis of the literature limited to peer-reviewed studies. Results: A confluence of factors combines to elevate the prevalence and risk of fatigue in the female nurse. Numerous measures have established that performance-based fatigue results from nursing work schedules in nurses. Data also demonstrate that fatigue accumulates across successive shifts. Recent evidence supports the use of objective fatigue measures, including psychomotor reaction time and muscle function-related variables. Current gaps in the literature are delineated in the text. Conclusions: Strategic and well-designed research studies, as well as recent technological advances in fatigue tracking tools have the potential to help workers, administrators, and organizations develop fatigue management programs that could reduce the heavy burdens of fatigue on a multitude of health, safety, and economical outcomes.

Translational simulation: from description to action

This article describes an operational framework for implementing translational simulation in everyday practice. The framework, based on an input-process-output model, is developed from a critical review of the existing translational simulation literature and the collective experience of the authors' affiliated translational simulation services. The article describes how translational simulation may be used to explore work environments and/or people in them, improve quality through targeted interventions focused on clinical performance/patient outcomes, and be used to design and test planned infrastructure or interventions. Representative case vignettes are used to show how the framework can be applied to real world healthcare problems, including clinical space testing, process development, and culture. Finally, future directions for translational simulation are discussed. As such, the article provides a road map for practitioners who seek to address health service outcomes using translational simulation.

Having Our “Omic” Cake and Eating It Too?: Evaluating User Response to Using Blockchain Technology for Private and Secure Health Data Management and Sharing

This paper reports on end users' perspectives on the use of a blockchain solution for private and secure individual “omics” health data management and sharing. This solution is one output of a multidisciplinary project investigating the social, data, and technical issues surrounding application of blockchain technology in the context of personalized healthcare research. The project studies potential ethical, legal, social, and cognitive constraints of self-sovereign healthcare data management and sharing, and whether such constraints can be addressed through careful design of a blockchain solution.

The views of New Zealand general practitioners and patients on a proposed risk assessment and communication tool: a qualitative study using Normalisation Process Theory

BACKGROUND

Communicating risks of medication harm and obtaining informed consent is difficult due to structural barriers, language and cultural practices, bias and a lack of resources appropriately tailored for the health literacy of most patients. A decision support tool was proposed to alert prescribers of risk and provide tailored information for patients to facilitate informed decision-making with patients and their whānau (family) around medication use. Patient and prescriber co-design was used to ensure the tool was designed to best meet the needs of end-users and avoid increasing health inequity. This paper describes the first stage of the co-design process.

METHOD

Normalisation Process Theory (NPT) was used to prospectively evaluate the tool. Semi-structured interviews were held with fifteen patients (five Māori, five Pasifika and five NZ European) and nine general practitioners (two Māori and seven European).

RESULTS

Three themes were identified, which related to the three NPT concepts most relevant to developing the tool. Theme 1 (coherence: meaning and sense making by participants) explored participants' understanding of prescribing safety, medication harm and risk, which is based on experience. Patients want as much information as possible about their medications and risk, but doctors find it difficult to communicate that information. Theme 2 related to the NPT concept of cognitive participation (commitment and engagement by participants) explored what participants thought about a prescribing decision support tool. Participants were cautiously optimistic, but worried about potential harm arising from its use. They also identified requirements for the tool and features to avoid. Theme 3 describes the collective action required for successful implementation of the tool; namely, culturally safe and trustworthy doctor-patient relationships.

CONCLUSION

Patients and general practitioners provided different perspectives when prospectively evaluating the proposed risk assessment and communication tool. This co-design research identified important pre-requisites for the tool and features to avoid and novel ideas for the proposed tool. Overall participants supported the development of the proposed risk assessment and communication tool, but identified the important role that doctor-patient relationships would play to ensure successful implementation. The use of Māori and Pacific languages in the proposed tool may enhance engagement and understanding.

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis

OBJECTIVES

To systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.

DESIGN

Systematic review with meta-analyses.

METHODS

Included were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs-heterogeneity was assessed using I2 statistics.

RESULTS

Of 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).

CONCLUSIONS

This study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

How to improve the effectiveness and efficiency of Kangaroo Mother Care: a literature review of equipment supporting continuous Kangaroo Mother Care

OBJECTIVE

The objective of this study was to provide an overview of the equipment supporting Kangaroo Mother Care (KMC).

METHOD

The review adopted a five-stage methodological framework that included research question identification, relevant study identification and selection, and data charting, collating, summarizing, and reporting. We conducted reviews to analyze the current research on the design of KMC-supporting devices. Publications were identified from January 2008 to July 2020.

RESULTS

Using the inclusion criteria, 17 relevant studies were identified that concerned the design of supporting equipment for KMC. Five types of equipment improved the comfort of the mothers performing KMC, another five monitored the health and development of the infants, and four served as therapy for the infants. Three equipment types showed no significant effect in supporting KMC.

CONCLUSIONS

This study provides information on equipment that effectively and efficiently improves the quality of KMC.

Repurposing drug molecules for new pulmonary therapeutic interventions

Drug repurposing with novel strategies has substantially contributed to the identification and analysis of new molecules for better pulmonary intervention. This review would offer insights into the drug repurposing for effective pulmonary therapy. The review begins by explaining the relevant background knowledge of drug repurposing, the need for drug repurposing, and their potential advantages in treating pulmonary diseases. This article takes into account clinical trial problems, drug delivery challenges, regulatory issues, and human ergonomics along with chemistry manufacturing and control strategies for effective pulmonary drug repurposing. This article elaborates on pulmonary drug repurposing with help of strengths, weaknesses, opportunities, and threat analysis. In brief, this article is the first inclusive account of drug repurposing for better pulmonary therapy. Graphical abstract.

A process-based approach to exploring the information behavior of informal caregivers of people living with dementia

INTRODUCTION AND PURPOSE

Informal caregivers of persons living with dementia have significant unmet information needs that, if met, would better equip them to provide effective care. Despite the existence of health information technologies, websites, resources, and organizations dedicated to dementia caregiving, caregivers continue to report unmet information needs. Caregivers' continued unmet information needs suggest a misalignment between information products, and caregivers' information behavior-how caregivers generate, acquire, manage, use, communicate, and seek information. Researchers have developed conceptual models for understanding caregivers' information behavior, but these models are limited in that they are task-oriented, and they assume that caregivers' information needs will be met if they engage in information behavior. To address these limitations, the present study sought to explore caregivers' information behavior as a sociotechnical-systems-based process.

METHODS

We conduced semi-structured interviews with 30 self-identified caregivers to explore their daily experience of caregiving activities, including their information behavior. We applied a process-based conceptual framework that takes into account inputs, processes, outputs, and feedback mechanisms within a sociotechnical system to guide analysis. The process of interest was caregivers' information behavior as modeled by the information-seeking and communication model (ISCM). We conducted a deductive content analysis guided by the components of the ISCM. We then used team-based affinity diagramming to collapse and categorize the ISCM components into inputs, processes, outputs, and feedback.

RESULTS

We developed a conceptual model to depict caregivers' information behavior as a sociotechnical-systems-based process of inputs, processes, and outputs that feedback into the system. The conceptual model consisted of three inputs (i.e., information users, information providers, and information products), three information seeking and communication processes (i.e., information access, information interaction, and information assessment and processing), two outputs (i.e., utility and credibility), and feedback.

DISCUSSION AND CONCLUSION

Building on and addressing the gaps in previous information behavior models, our conceptual framework advances the previous task-level understandings of caregivers' information behavior into a comprehensive feedback-driven, process-level perspective consisting of context-based inputs, information seeking and communication processes, outputs, and feedback. A sociotechnical-systems-based understanding of caregivers' information behavior allows for misalignments between information providers and products, and caregivers' information behavior not only to be illuminated, but systematically addressed.

Using system dynamics modelling to show the effect of nurse workload on nurses' health and quality of care

The objective of the current study is to explore System Dynamics modelling to quantify and understand the effects of nursing workload on nurse burnout, absenteeism, and quality of patient care. A literature search was performed to identify the causal relationships between factors related to the problem and build a conceptual causal loop diagram. Each of these factors was then operationalised and a simulation model was built using quantitative empirical data from the literature, supplemented with expert input. The model results showed that long nurse shifts and work weeks double nurse fatigue levels, while increasing burnout by up to 6 times, absenteeism by up to 5 times, and medical errors for the patients increasing by up to 150%. The study demonstrates a novel application of System Dynamics in healthcare to examine the impact of management strategies and healthcare system design on nurses' wellbeing and on care quality. Practitioner summary: System Dynamics Modelling allows for the integration of available scientific evidence and expertise to reveal the relationship between nurse workload, burnout and care quality in terms of medical errors. Such models can reveal possible responses from proposed policy or system design changes that could not be quantified with conventional approaches. Abbreviations: HF: human factors; SD: system dynamics; CLD: causal loop diagram; OFAT: one factor at a time.

Development and evaluation of an electronic hospital referral system: a human factors approach

Coordinating care across hospitals has been identified as a patient safety risk as referrals are often paper-based and poorly documented. Electronic referral systems have the potential to improve the situation but can fail to gain uptake. We applied a human factors/ergonomics (HFE) approach to place analysis of local workflow and user engagement central to the development of a new regional electronic referral system. The intervention was evaluated with a before-and-after study. Referral quality improved, referrals containing sufficient clinical information for continuation of care increased from 36.9% to 83.5% and completeness of referral information significantly improved. There was a 35.7% reduction in the number of calls to the on-call specialist, and the mean period between admission and surgery for expedited transfers was reduced. Applying HFE informed design with use-based evidence; the system maintains sustained uptake three years after implementation. Reliable recording of information translates to better patient safety during inter-hospital transitions. Practitioners summary: This study developed, implemented and evaluated a clinical referral system using a human factors approach. Process analysis and usability studies were used to inform the application requirements and design. Region-wide implementation in hospitals resulted in the improved quality and completeness of clinical referral information and efficiencies in the referral process.

Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

BACKGROUND

Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety.

METHODS

Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted.

RESULTS

In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8-29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7-13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9-13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4-23). Administration technique errors represented 53% (IQR 52.7-67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1-46) of prescribed medication; 70.3% (Range 50-78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors.

CONCLUSIONS

Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.

Waiting Time: The Expectations and Preferences of Patients in a Paediatric OPD

Quality healthcare and satisfaction are gradually emerging as important areas, which need much attention. The factors of patient satisfaction have been identified under varied conditions globally. In the Indian context, one key patient satisfaction factor has been attributed to waiting time. Long waiting time has been one of the major reasons of patient dissatisfaction and assumes significance when associated with paediatric events. The following study has successfully identified key attributes, which are associated with long waiting times within paediatric outpatient department (OPD) settings. The possible implications of the long waiting periods have been recorded through semi-structured interviews, and further in-depth analysis of individual factors were carried out to predict the probable outcomes.

The qualitative exploratory study design has helped to understand the perception of parents/care givers (in case of neonates and toddlers) and adolescents, thereby successfully highlighting the need for further study in the patient satisfaction domain involving paediatric population. The various implications which the waiting time has on them have been taken into consideration. The inter-related themes have been identified after analyzing the interviews. These substantiate the fact that designing innovative mitigation strategies on proper and timely communication, updated technological know-how, improvising hospital protocols for better operational processes and coordination among the staff can go a long way in enhancing the patient/parent experience within OPD settings.

Beyond Disease: Technologies for Health Promotion

Health promotion is defined by the World Health Organization as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.” This is different from the bulk of formal healthcare processes, which are characterized by the treatment of an established disease. Much important human factors research and practice has been done to improve the healthcare delivery process and increasingly human factors professionals are also involved in work on health promotion. Such work has included examining the use and usability of wearable fitness tracking devices, studies of online health information seeking by healthy individuals, and human factors research on social robots for older adults, to name but a few examples. We discuss human factors applications in health promotion, focusing on examples from technology-related research.

Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach

BACKGROUND AND OBJECTIVES

Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success.

RESEARCH DESIGN AND METHODS

This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success.

RESULTS

The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload.

DISCUSSION AND IMPLICATIONS

Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.

Exploring leadership within a systems approach to reduce health care-associated infections: A scoping review of one work system model

BACKGROUND

Despite efforts to prevent health care-associated infections (HAIs), these infections continue to challenge health care systems. The Centers for Disease Control and Prevention emphasizes implementation of evidence-based practices. Within the complex health care environment, sustained implementation calls for work systems that harness expertise of interprofessional teams, which, in turn, calls for suitable executive, mid-level, and local leadership. The purpose of this review is to highlight the need to study leadership when using a systems approach to reduce HAIs.

METHODS

This is a scoping review of HAI studies that used a systems engineering model called the Systems Engineering Initiative for Patient Safety model. We examined if and how leadership was addressed within 1 systems approach.

RESULTS

We found 15 studies using the Systems Engineering Initiative for Patient Safety model and, of these, leadership was directly mentioned in 3 studies. In the remaining studies, reference to leadership may be inferred by use of terms such as teamwork, managerial oversight, climate and culture, staffing support, and institutional/administrative support.

CONCLUSIONS

Research is needed to bring recognition of the role of leadership within a work systems approach to reducing HAIs. We need further examination of leadership attributes and communication behaviors that allow staff to diffuse and sustain best practices to prevent HAIs.

Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital

We established a Patient Safety Learning Laboratory comprising 2 core and 3 individual project teams to introduce a suite of digital health tools integrated with our electronic health record to identify, assess, and mitigate threats to patient safety in real time. One of the core teams employed systems engineering (SE) and human factors (HF) methods to analyze problems, design and develop improvements to intervention components, support implementation, and evaluate the system of systems as an integrated whole. Of the 29 participants, 19 and 16 participated in surveys and focus groups, respectively, about their perception of SE and HF. We identified 7 themes regarding use of the 12 SE and HF methods over the 4-year project. Qualitative methods (interviews, focus, groups, observations, usability testing) were most frequently used, typically by individual project teams, and generated the most insight. Quantitative methods (failure mode and effects analysis, simulation modeling) typically were used by the SE and HF core team but generated variable insight. A decentralized project structure led to challenges using these SE and HF methods at the project and systems level. We offer recommendations and insights for using SE and HF to support digital health patient safety initiatives.

Work System Assessment to Facilitate the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use: A Case Study Using a Human Factors Engineering Approach

BACKGROUND

Work system assessments can facilitate successful implementation of quality improvement programs. Using a human factors engineering approach, we conducted a work system assessment to facilitate the dissemination of a quality improvement program for optimizing blood culture use in pediatric intensive care units at 2 hospitals.

METHODS

Semistructured face-to-face interviews were conducted with clinicians from Johns Hopkins All Children's Hospital and University of Virginia Medical Center. Interview data were analyzed using qualitative content analysis.

RESULTS

Blood culture-ordering practices are influenced by various work system factors, including people, tasks, tools and technologies, the physical environment, organizational conditions, and the external environment. A clinical decision-support tool could facilitate implementation by (1) standardizing blood culture-ordering practices, (2) ensuring that prescribing clinicians review the patient's condition before ordering a blood culture, (3) facilitating critical thinking, and (4) empowering nurses to communicate with physicians and advocate for adherence to blood culture-ordering guidelines.

CONCLUSION

The success of interventions for optimizing blood culture use relies heavily on the local context. A work system analysis using a human factors engineering approach can identify key areas to be addressed for the successful dissemination of quality improvement interventions.

Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach

BACKGROUND AND OBJECTIVES

Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success.

RESEARCH DESIGN AND METHODS

This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success.

RESULTS

The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload.

DISCUSSION AND IMPLICATIONS

Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.

The Impact of New Graduate Nurse Transition Programs on Competency Development and Patient Safety: An Integrative Review

Stronger evidence on the value of new graduate nurse transition programs is needed to justify the cost and warrant expansion of these programs to more health systems. The aim of this integrative review was to critically analyze published research on the relationship between new graduate nurse transition programs and patient safety outcomes. Limited evidence was found on actual safety improvement; rather, transition programs have predominately measured the development of competency as a process outcome variable for improving patient safety. A systems model is proposed to guide future research examining structure, process, and outcome variables, linking transition programs with patient outcomes.