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Salwei ME, Ancker JS, Weinger MB. The decision aid is the easy part: workflow challenges of shared decision making in cancer care. J Natl Cancer Inst 2023; 115:1271-1277. [PMID: 37421403 DOI: 10.1093/jnci/djad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023] Open
Abstract
Delivering high-quality, patient-centered cancer care remains a challenge. Both the National Academy of Medicine and the American Society of Clinical Oncology recommend shared decision making to improve patient-centered care, but widespread adoption of shared decision making into clinical care has been limited. Shared decision making is a process in which a patient and the patient's health-care professional weigh the risks and benefits of different options and come to a joint decision on the best course of action for that patient on the basis of their values, preferences, and goals for care. Patients who engage in shared decision making report higher quality of care, whereas patients who are less involved in these decisions have statistically significantly higher decisional regret and are less satisfied. Decision aids can improve shared decision making-for example, by eliciting patient values and preferences that can then be shared with clinicians and by providing patients with information that may influence their decisions. However, integrating decision aids into the workflows of routine care is challenging. In this commentary, we explore 3 workflow-related barriers to shared decision making: the who, when, and how of decision aid implementation in clinical practice. We introduce readers to human factors engineering and demonstrate its potential value to decision aid design through a case study of breast cancer surgical treatment decision making. By better employing the methods and principles of human factors engineering, we can improve decision aid integration, shared decision making, and ultimately patient-centered cancer outcomes.
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Affiliation(s)
- Megan E Salwei
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica S Ancker
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew B Weinger
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Reale C, Ariosto DA, Weinger MB, Anders S. Medication Safety Amid Technological Change: Usability Evaluation to Inform Inpatient Nurses' Electronic Health Record System Transition. J Gen Intern Med 2023; 38:982-990. [PMID: 37798581 PMCID: PMC10593701 DOI: 10.1007/s11606-023-08278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/13/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Electronic health record (EHR) system transitions are challenging for healthcare organizations. High-volume, safety-critical tasks like barcode medication administration (BCMA) should be evaluated, yet standards for ensuring safety during transition have not been established. OBJECTIVE Identify risks in common and problem-prone medication tasks to inform safe transition between BCMA systems and establish benchmarks for future system changes. DESIGN Staff nurses completed simulation-based usability testing in the legacy system (R1) and new system pre- (R2) and post-go-live (R3). Tasks included (1) Hold/Administer, (2) IV Fluids, (3) PRN Pain, (4) Insulin, (5) Downtime/PRN, and (6) Messaging. Audiovisual recordings of task performance were systematically analyzed for time, navigation, and errors. The System Usability Scale measured perceived usability and satisfaction. Post-simulation interviews captured nurses' qualitative comments and perceptions of the systems. PARTICIPANTS Fifteen staff nurses completed 2-3-h simulation sessions. Eleven completed both R1 and R2, and seven completed all three rounds. Clinical experience ranged from novice (< 1 year) to experienced (> 10 years). Practice settings included adult and pediatric patient populations in ICU, stepdown, and acute care departments. MAIN MEASURES Task completion rates/times, safety and non-safety-related use errors (interaction difficulties), and user satisfaction. KEY RESULTS Overall success rates remained relatively stable in all tasks except two: IV Fluids task success increased substantially (R1: 17%, R2: 54%, R3: 100%) and Downtime/PRN task success decreased (R1: 92%, R2: 64%, R3: 22%). Among the seven nurses who completed all rounds, overall safety-related errors decreased 53% from R1 to R3 and 50% from R2 to R3, and average task times for successfully completed tasks decreased 22% from R1 to R3 and 38% from R2 to R3. CONCLUSIONS Usability testing is a reasonable approach to compare different BCMA tasks to anticipate transition problems and establish benchmarks with which to monitor and evaluate system changes going forward.
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Affiliation(s)
- Carrie Reale
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Institute for Medicine and Public Health, and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Deborah A Ariosto
- Department of Patient Care Services, Vanderbilt University Medical Center, Nashville, USA
| | - Matthew B Weinger
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Institute for Medicine and Public Health, and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, USA
| | - Shilo Anders
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Institute for Medicine and Public Health, and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, USA
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Vanneman MW, Balakrishna A, Lang AL, Eliason KD, Payette AM, Xu X, Driscoll WD, Donovan KM, Deng H, Dzik WH, Levine WC. Improving Transfusion Safety in the Operating Room With a Barcode Scanning System Designed Specifically for the Surgical Environment and Existing Electronic Medical Record Systems: An Interrupted Time Series Analysis. Anesth Analg 2020; 131:1217-1227. [PMID: 32925343 DOI: 10.1213/ane.0000000000005084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Manual processes for verifying patient identification before blood transfusion and documenting this pretransfusion safety check are prone to errors, and compliance with manual systems is especially poor in urgent operating room settings. An automated, electronic barcode scanner system would be expected to improve pretransfusion verification and documentation. METHODS Audits were conducted of blood transfusion documentation under a manual paper system from January to October 2014. An electronic barcode scanning system was developed to streamline transfusion safety checking and automate documentation. This system was implemented in 58 operating rooms between October and December 2014, with follow-up compliance audits through December 2015. The association of barcode scanner implementation with transfusion documentation compliance was assessed using an interrupted time series analysis. Anesthesia providers were surveyed regarding their opinions on the electronic system. In mid-2016, the scanning system was modified to transfer from the Metavision medical record system to Epic OpTime. Follow-up analysis assessed performance of this system within Epic during 2017. RESULTS In an interrupted time series analysis, the proportion of units with compliant documentation was estimated to be 19.6% (95% confidence interval [CI], 10.7-25.6) the week before scanner implementation, and 74.4% (95% CI, 59.4-87.4) the week after implementation. There was a significant postintervention level change (odds ratio 10.80, 95% CI, 6.31-18.70; P < .001) and increase in slope (odds ratio 1.14 per 1-week increase, 95% CI, 1.11-1.17; P < .001). After implementation, providers chose to use the new electronic system for 98% of transfusions. Across the 2 years analyzed (15,997 transfusions), the electronic system detected 45 potential transfusion errors in 27 unique patients, and averted transfusion of 36 mismatched blood products into 20 unique patients. A total of 69%, 86%, and 88% of providers reported the electronic system improved patient safety, blood transfusion workflow, and transfusion documentation, respectively. When providers used the barcode scanner, no transfusion errors or reactions were reported. The scanner system was successfully transferred from Metavision to Epic without retraining staff or changing workflows. CONCLUSIONS A barcode-based system designed for easy integration to different commonly used anesthesia information management systems was implemented in a large urban academic hospital. The system allows a single user with the assistance of a software system to perform and document pretransfusion safety verification. The system improved transfusion documentation compliance, averted potential transfusion errors, and became the preferred method of blood transfusion safety checking.
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Affiliation(s)
| | | | - Angela L Lang
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Kent D Eliason
- The Blood Transfusion Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Alyssa M Payette
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Xiaojun Xu
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | | | | | - Hao Deng
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Walter H Dzik
- The Blood Transfusion Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Wilton C Levine
- From the Department of Anesthesia, Critical Care and Pain Medicine
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Robinson S, Harris A, Atkinson S, Atterbury C, Bolton-Maggs P, Elliott C, Hawkins T, Hazra E, Howell C, New H, Shackleton T, Shreeve K, Taylor C. The administration of blood components: a British Society for Haematology Guideline. Transfus Med 2017; 28:3-21. [PMID: 29110357 DOI: 10.1111/tme.12481] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/04/2017] [Accepted: 09/16/2017] [Indexed: 01/02/2023]
Affiliation(s)
- S Robinson
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Harris
- Diagnostic and Therapeutic Services, NHS Blood and Transplant (NHSBT), Birmingham, UK
| | - S Atkinson
- Department Anaesthesia, Belfast Health and Social Care Trust, Chair of Northern Ireland Transfusion Committee, Northern, Ireland
| | - C Atterbury
- Department of Haematology, The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust, King's Lyn, UK
| | - P Bolton-Maggs
- Serious Hazards of Transfusion (SHOT) Office, NHSBT, Manchester, UK
| | - C Elliott
- Transfusion, South Tees Hospitals NHS Trust, Middlesbrough, UK
| | - T Hawkins
- Department of Haematology, Royal Berkshire NHS Foundation Trust, Reading, Berkshire, UK
| | - E Hazra
- NHS National Services Scotland, Scottish National Blood Transfusion Service - Better Blood Transfusion, United Kingdom of Great Britain & Northern Ireland
| | - C Howell
- Diagnostic and Therapeutic Services, NHSBT, Bristol, UK
| | - H New
- Products, NHSBT, London, UK
| | - T Shackleton
- Department of Haematology, Alder Hey Hospital Children's NHS Foundation Trust, Liverpool, UK
| | - K Shreeve
- Better Blood Transfusion Team, Welsh Blood Service, Pencoed, UK
| | - C Taylor
- Haematology, Dudley Group of Hospitals NHS Foundation Trust, Dudley, UK
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Simulation as a toolkit-understanding the perils of blood transfusion in a complex health care environment. Adv Simul (Lond) 2016; 1:32. [PMID: 29450001 PMCID: PMC5806277 DOI: 10.1186/s41077-016-0032-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/15/2016] [Indexed: 11/06/2022] Open
Abstract
Background Administration of blood is a complex process requiring vigilance and effective teamwork. Despite strict policies and training on blood administration, errors still occur and can lead to mistransfusion with adverse patient outcomes. We used an in situ simulated scenario within an operating room (OR) to identify weaknesses in the current process and hazards that could contribute to mistransfusion. Methods A process checklist of critical steps of safe transfusion was developed based on a large academic centre’s internal hospital policy and practice. Ten standardized operating room scenarios were conducted involving management of postoperative bleeding. Scenarios lasted 20 min or until blood transfusion was started. Debriefing followed immediately. Video recordings were reviewed, scored, and evaluated for team performance. Latent safety threats were identified. Focus groups further helped to identify rationale for decisions made. Participants completed questionnaires to evaluate the exercise. Results Forty-three experienced OR professionals participated. Of the 19 steps identified as essential for the safe administration of blood components, the median number of steps correctly completed per team was 11. The largest number of errors occurred when different team members interacted and during the immediate pre-transfusion check. We report that this type of learning immediately increased participants’ self-reported ability to perform in a team (90%) and to improve clinical care (88%). Conclusions In situ simulation is valuable in identifying common susceptibilities in blood administration error in a complex healthcare organization. Administrators and clinicians may wish to use simulation as an opportunity for system improvement in the delivery of quality care.
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Probst CA, Wolf L, Bollini M, Xiao Y. Human factors engineering approaches to patient identification armband design. APPLIED ERGONOMICS 2016; 52:1-7. [PMID: 26360188 DOI: 10.1016/j.apergo.2015.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 06/05/2023]
Abstract
The task of patient identification is performed many times each day by nurses and other members of the care team. Armbands are used for both direct verification and barcode scanning during patient identification. Armbands and information layout are critical to reducing patient identification errors and dangerous workarounds. We report the effort at two large, integrated healthcare systems that employed human factors engineering approaches to the information layout design of new patient identification armbands. The different methods used illustrate potential pathways to obtain standardized armbands across healthcare systems that incorporate human factors principles. By extension, how the designs have been adopted provides examples of how to incorporate human factors engineering into key clinical processes.
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Affiliation(s)
- C Adam Probst
- Baylor Scott&White Health, Office of Patient Safety, 8080 North Central Expressway, Suite 500, Dallas, TX, 75206, USA.
| | - Laurie Wolf
- Barnes Jewish Hospital, Operational Excellence Department, One Barnes-Jewish Hospital Plaza, St. Louis, Missouri, 63110, USA
| | - Mara Bollini
- Washington University School of Medicine Department of Anesthesiology, 660 S. Euclid Avenue, Campus Box 8054, St. Louis, Missouri, 63110, USA
| | - Yan Xiao
- Baylor Scott&White Health, Office of Patient Safety, 8080 North Central Expressway, Suite 500, Dallas, TX, 75206, USA
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McCrory B, Lowndes BR, LaGrange CA, Miller EE, Hallbeck MS. Comparative usability testing of conventional and single incision laparoscopic surgery devices. HUMAN FACTORS 2013; 55:619-631. [PMID: 23829035 DOI: 10.1177/0018720812465082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE The objective was to perform competitive usability testing to assess the user experience of conventional laparoscopic and laparoendoscopic single-site surgery (LESS) devices. BACKGROUND Recent advancements in single-incision instrumentation have created more interest in and usage of LESS. However, neither LESS nor its novel multichannel access devices have been thoroughly studied. METHOD Using a simulation test bed and standardized laparoscopic surgery task, the user experience of three commercially available LESS devices was compared to conventional laparoscopic ports based on time on task, errors, task success, and perceived ease of use. RESULTS There were no significant differences between devices for time on task, errors, or task success (p > .05). For all devices, there were significantly more recoverable than unrecoverable errors, and errors occurred more frequently during the second phase of the task when the dominant hand was more active (p < .0001). Conventional laparoscopy was rated as easier to use than were the LESS devices (p < .01). CONCLUSION Device performance of a basic laparoscopic task was similar in both conventional laparoscopy and LESS. Each of the LESS devices facilitated efficient and accurate aiming and grasping movements compared to conventional laparoscopy. Further investigation of human factors and ergonomics of LESS is needed to further develop, evaluate, and refine single-site surgery technologies to create a user experience equivalent to conventional laparoscopy. APPLICATION Competitive usability testing of medical devices yields objective performance data that can be used to inform purchase decisions and future device design improvements.
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Affiliation(s)
- Bernadette McCrory
- Department of Biomedical Engineering, University of Nebraska-Lincoln, 342 Nebraska Hall, Lincoln, NE 68588-0526, USA.
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Jeskey M, Card E, Nelson D, Mercaldo ND, Sanders N, Higgins MS, Shi Y, Michaels D, Miller A. Nurse adoption of continuous patient monitoring on acute post-surgical units: managing technology implementation. J Nurs Manag 2011; 19:863-75. [PMID: 21988434 DOI: 10.1111/j.1365-2834.2011.01295.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To report an exploratory action-research process used during the implementation of continuous patient monitoring in acute post-surgical nursing units. BACKGROUND Substantial US Federal funding has been committed to implementing new health care technology, but failure to manage implementation processes may limit successful adoption and the realisation of proposed benefits. Effective approaches for managing barriers to new technology implementation are needed. METHOD Continuous patient monitoring was implemented in three of 13 medical/surgical units. An exploratory action-feedback approach, using time-series nurse surveys, was used to identify barriers and develop and evaluate responses. Post-hoc interviews and document analysis were used to describe the change implementation process. RESULTS Significant differences were identified in night- and dayshift nurses' perceptions of technology benefits. Research nurses' facilitated the change process by evolving 'clinical nurse implementation specialist' expertise. CONCLUSIONS Health information technology (HIT)-related patient outcomes are mediated through nurses' acting on new information but HIT designed for critical care may not transfer to acute care settings. Exploratory action-feedback approaches can assist nurse managers in assessing and mitigating the real-world effects of HIT implementations. IMPLICATIONS FOR NURSING MANAGEMENT It is strongly recommended that nurse managers identify stakeholders and develop comprehensive plans for monitoring the effects of HIT in their units.
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Affiliation(s)
- Mary Jeskey
- Department of Anesthesiology, Center for Interdisciplinary Health Workforce Studies, USA
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