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Wooldridge AR, Morgan J, Ramadhani WA, Hanson K, Vazquez-Melendez E, Kendhari H, Shaikh N, Riech T, Mischler M, Krzyzaniak S, Barton G, Formella KT, Abbott ZR, Farmer JN, Ebert-Allen R, Croland T. Interactions in Sociotechnical Systems: Achieving Balance in the Use of an Augmented Reality Mobile Application. HUMAN FACTORS 2024; 66:658-682. [PMID: 35549474 DOI: 10.1177/00187208221093830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE We explore relationships between barriers and facilitators experienced by users to understand dynamic interactions in sociotechnical systems and improve a mobile phone-based augmented reality application that teaches users about the contents of a standardized pediatric code cart. BACKGROUND Understanding interactions between performance obstacles and facilitators can provide guidance to (re)designing sociotechnical systems to improve system outcomes. Clinicians should know about contents and organization of code carts, and an augmented reality mobile application may improve that knowledge but changes the sociotechnical system in which they learn. Prior work identified barriers and facilitators impacting the use of this application-participants described dimensions together, indicating interactions that are explored in the current study. METHOD We conducted four focus groups (number of clinicians = 18) and two interviews with clinicians who used the application. We performed a secondary analysis of focus group data exploring interactions between previously identified barriers and facilitators to application use. We used epistemic network analysis to visualize these interactions. RESULTS Work system barriers interacted with barriers and facilitators interacted with facilitators to amplify cumulative negative or positive impact, respectively. Facilitators balanced barriers, mitigating negative impact. Facilitators also exacerbated barriers, worsening negative impact. CONCLUSION Barriers and facilitators interact and can amplify, balance, and exacerbate each other-notably, positives are not always positive. To obtain desired outcomes, interactions must be further considered in sociotechnical system design, for example, the potential improvements to the application we identified.
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Affiliation(s)
| | | | | | - Keith Hanson
- University of Illinois College of Medicine at Peoria, IL, USA
| | | | | | - Nadia Shaikh
- University of Illinois College of Medicine at Peoria, IL, USA
| | - Teresa Riech
- University of Illinois College of Medicine at Peoria, IL, USA
| | | | | | - Ginger Barton
- OSF HealthCare Children's Hospital of Illinois, Peoria, IL, USA
| | - Kyle T Formella
- Jump Simulation, Peoria, IL, USA
- OSF HealthCare, Peoria, IL, USA
| | | | - John N Farmer
- Jump Simulation, Peoria, IL, USA
- OSF HealthCare, Peoria, IL, USA
| | | | - Trina Croland
- University of Illinois College of Medicine at Peoria, IL, USA
- OSF HealthCare Children's Hospital of Illinois, Peoria, IL, USA
- Jump Simulation, Peoria, IL, USA
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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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Frazier M, Webster K, Dewan M, Hutson T, Collins K, Fettig T, Grooms T, Cordray M, Tegtmeyer K. Improving Usability of the Pediatric Code Cart by Combining Lean and Human Factors Principles. Pediatr Qual Saf 2023; 8:e676. [PMID: 37551262 PMCID: PMC10402944 DOI: 10.1097/pq9.0000000000000676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 06/22/2023] [Indexed: 08/09/2023] Open
Abstract
Cardiac arrests are common in hospitalized children. Well-organized code carts are needed during these events to help staff efficiently find supplies and medications for the patient. This study aimed to improve the efficiency and utilization of the code cart at a major academic pediatric medical center. Methods This quality improvement project used a phased approach to redesign the code cart. A multidisciplinary team used Lean and Human Factors principles to improve the efficiency and intuitiveness of the redesigned cart. Nurses and respiratory therapists participated in simulations asking for certain supplies with the original and redesigned code cart and filled out surveys for feedback on each code cart. Facilitators measured retrieval times during each simulation. Results We performed 10 simulations with the original code cart and 13 with the redesigned code cart. Staff could find intraosseous access equipment more quickly (23.9 versus 46.4 seconds; P = 0.003). In addition, staff reported they were less likely to open the wrong drawer or grab the wrong equipment and that the redesigned code cart was overall more well organized than the original code cart. Finally, the redesigned code cart reduced the cost by over 800 dollars per full cart restock. Conclusion Revising the code cart using Lean and Human Factors improves efficiency and usability and can contribute to cost savings.
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Affiliation(s)
- Maria Frazier
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kristen Webster
- Patient Safety, Regulatory, and Accreditation, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maya Dewan
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tamara Hutson
- Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kelly Collins
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tina Fettig
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Taylor Grooms
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Ken Tegtmeyer
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Nair VB, Joseph S, Thomas S, Sharvana S, PK P, Mathew S. Knowledge and Practice of Internship Students on the Emergency Crash Cart System in a Selected Tertiary Care Hospital, Mangaluru, Karnataka, India. JOURNAL OF HEALTH AND ALLIED SCIENCES NU 2022. [DOI: 10.1055/s-0042-1759508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
Introduction: A crash cart is the trolley for storing lifesaving equipment and drugs in a hospital. During an emergency situation, nurses are left with confusion and hurry in getting the emergency medication and equipment. Typically, the crash cart system remains locked until a code blue triage is initiated by the hospital. This lack of exposure leads to poor competency and confident in performing essential tasks during a code blue. A well-organized crash cart system can save a lot of time and confusion during an emergency, which in turn can save a life.
Aim The aim of this study was to identify the knowledge and practice of internship students on emergency crash cart system and to find the correlation between knowledge and practices of nursing internship students on maintenance of emergency crash cart system.
Materials and Methods A descriptive correlative research study was conducted among 93 nursing internship students tertiary care hospital, Mangaluru, Karnataka, India. The samples were selected by using purposive sampling techniques. Demographic proforma, structured knowledge questionnaire on knowledge regarding emergency crash cart system with 32 items was used to determine the level of knowledge and observation practice checklist with 24 items was used to assess the practice of internship students on maintenances of emergency crash cart system. Descriptive and inferential statistics was used to analyze the collected data.
Results Majority (89; 95.7%) of the internship students are in the age group of 20 to 25 years and most (59; 63.4%) of internship students are working in wards. Of that 79 (84.9%) internship students have average knowledge with mean 18.1, median 19, and standard deviation (SD) 3.2. Majority 90 (96.7%) of the internship students have satisfactory practice on emergency crash carts with mean 22.9, median 23, and SD 1. 11. There is a moderate positive linear relationship between knowledge and practice scores of the internship students on the emergency crash cart system (r = 0.38, df =92, p= 0.05).
Conclusions The study concludes nursing internship students have average knowledge about emergency crash cart system. And the practice of internship students on maintenance of crash cart was satisfactory. The study thus implies the need for frequent reinforcement and training programs, which may help the internship students to improve knowledge on emergency crash cart systems. There should be clear instructions about the arrangement and use of a crash cart in each and every unit.
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Affiliation(s)
- Varsha B. Nair
- Department of Community Health Nursing, Yenepoya Nursing College, Yenepoya (Deemed to be) University, Mangaluru, Karnataka, India
| | - Shilpa Joseph
- Department of Community Health Nursing, Yenepoya Nursing College, Yenepoya (Deemed to be) University, Mangaluru, Karnataka, India
| | - Shintu Thomas
- Department of Community Health Nursing, Yenepoya Nursing College, Yenepoya (Deemed to be) University, Mangaluru, Karnataka, India
| | - Sharvana Sharvana
- Department of Community Health Nursing, Yenepoya Nursing College, Yenepoya (Deemed to be) University, Mangaluru, Karnataka, India
| | - Pranav PK
- Department of Community Health Nursing, Yenepoya Nursing College, Yenepoya (Deemed to be) University, Mangaluru, Karnataka, India
| | - Shycil Mathew
- Department of Community Health Nursing, Yenepoya Nursing College, Yenepoya (Deemed to be) University, Mangaluru, Karnataka, India
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Optimal Crash Cart Configuration for a Surgical NICU: Utilizing Human Factors Principles. Adv Neonatal Care 2021; 21:289-396. [PMID: 33278105 DOI: 10.1097/anc.0000000000000814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neonates admitted to cardiac and surgical neonatal intensive care units (NICUs) are at an increased risk of requiring emergency lifesaving interventions that require the use of both Neonatal Resuscitation Program (NRP) and Pediatric Advanced Life Support (PALS) algorithms. Clinicians working within the surgical NICU must be able to access emergency equipment and medications quickly in order to respond to critical situations. A crash cart that integrates human factors principles and supports both the NRP and PALS algorithms is necessary to promote patient safety for this high-risk population. PURPOSE A multidisciplinary quality improvement project constructed an optimal crash cart configuration that embedded human factors principles and supported clinical workflow by reflecting both the NRP and the PALS algorithms in an NICU that cares for cardiac and surgical patients. METHODS A crash cart working group including frontline NICU staff, simulation experts, and a human factors specialist was formed within a surgical NICU. Human factors principles were utilized to align the organization of the cart with the NRP and PALS algorithms to increase the efficiency and intuitiveness of the cart. The new crash cart configuration was usability tested through simulation, revised on the basis of clinical feedback, and then implemented in a clinical setting. Data were collected following implementation of the new crash cart to validate that the new configuration was viewed as a significant improvement. The Plan-Do-Study-Act cycle was used to make improvements and capture outcome indicators. RESULTS Evaluation data collected both during usability simulation testing and in situ within the NICU clinical environment indicated that the revised crash cart scored higher on Likert scale response questions than the previous crash cart. IMPLICATIONS FOR PRACTICE Human factors science, in combination with frontline user engagement, should be utilized to create intuitive crash cart configurations, which are then tested in a simulation environment and evaluated in situ in the NICU. IMPLICATIONS FOR RESEARCH Further research around crash cart design within NICUs that use multiple lifesaving algorithms would add to the paucity of research around the impact of human factors theory in the utilization of lifesaving equipment and medications within this specific population.
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Chang H, Silva M, Giner A, Diaz Y, Sosa MA, Knudsen G, Mahavadi AK, Ellis J, Cameron A, Núñez CAQ, Wynter MA, O'Phelan K, Komotar RJ, Cajigas I. Ventriculostomy supply cart decreases time-to-external ventricular drain placement in the emergency department. Surg Neurol Int 2021; 12:362. [PMID: 34350056 PMCID: PMC8330128 DOI: 10.25259/sni_371_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Minimizing time-to-external ventricular drain (EVD) placement in the emergency department (ED) is critical. We sought to understand factors affecting time-to-EVD placement through a quality improvement initiative. Methods: The use of process mapping, root cause analyses, and interviews with staff revealed decentralized supply storage as a major contributor to delays in EVD placement. We developed an EVD “crash cart” as a potential solution to this problem. Time-to-EVD placement was tracked prospectively using time stamps in the electronic medical record (EMR); precart control patients were reviewed retrospectively. Results: The final cohorts consisted of 33 precart and 18 postcart cases. The mean time-to-EVD in the precart group was 99.09 min compared to 71.88 min in the postcart group (two-tailed t-test, P = 0.023). Median time-to-EVD was 92 min in the precart group compared to 64 min in the postcart group (rank sum test, P = 0.0165). Postcart patients trended toward improved outcomes with lower modified Rankin score scores at 1 year, but this did not reach statistical significance (two-tailed t-test, P = 0.177). Conclusion: An EVD “crash cart” is a simple intervention that can significantly reduce time-to-EVD placement and may improve outcomes in patients requiring an EVD.
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Affiliation(s)
- Henry Chang
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Michael Silva
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Alexander Giner
- Department of Emergency, Jackson Memorial Hospital, Miami, Florida, United States
| | - Yvonne Diaz
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida, United States
| | - Marie Ann Sosa
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida, United States
| | - Grace Knudsen
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Anil K Mahavadi
- Department of Neurosurgery, University of Alabama Birmingham School of Medicine, Birmingham, Alabama, United States
| | - June Ellis
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida, United States
| | - Arlene Cameron
- Department of Orthopedic, Division of Neurology and Surgery, Jackson Memorial Hospital, Miami, Florida, United States
| | | | - Millicent A Wynter
- Department of Nursing Education, Jackson Memorial Hospital, Miami, Florida, United States
| | - Kristine O'Phelan
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Ricardo J Komotar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Iahn Cajigas
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, United States
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Esteban Garcia JM, Mato Mañas D, Marco De Lucas E, Garcia Catalan G, Lopez Gomez P, Santos Jimenez C, Laez RM. Invisible compression, anterior fossa tumor causing trigeminal neuralgia. Surg Neurol Int 2021; 12:106. [PMID: 33880211 PMCID: PMC8053474 DOI: 10.25259/sni_371_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 02/20/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Trigeminal neuralgia secondary to posterior and middle fossae tumors, whether ipsilateral or contralateral, has been well described. However, this disabling disease has never been reported in the context of anterior fossa neoplasms. Case Description: A 75-year-old female with right hemifacial pain was diagnosed with an anterior clinoid meningioma. Despite neuroimaging did not show any apparent anatomical or neurovascular conflict, a detailed MRI analysis revealed a V3 hyperintensity. Not only symptoms completely resolved after surgical resection but also this radiological sign disappeared. Nowadays, the patient remains asymptomatic and V3 hyperintensity has not reappeared during her follow-up. Conclusion: A surgical definitive treatment can be offered to patients suffering from trigeminal neuralgia secondary to lesions adjacent to Gasserian ganglion or trigeminal branches. In this respect, posterior and middle fossae tumors are well-reported etiologies. Nevertheless, in the absence of evident compression, other neoplasms located in the vicinity of these critical structures and considered as radiological findings may be involved in trigeminal pain. Microvascular and pressure gradient changes could be an underlying cause of these symptoms in anterior skull base lesions. Here, we report the case of a patient with uncontrollable hemifacial pain resolved after anterior clinoid meningioma removal.
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Affiliation(s)
| | - David Mato Mañas
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Enrique Marco De Lucas
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Guillermo Garcia Catalan
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Patricia Lopez Gomez
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Carlos Santos Jimenez
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Ruben Martin Laez
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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Hunie M, Desse T, Fenta E, Teshome D, Gelaw M, Gashaw A. Availability of Emergency Drugs and Essential Equipment in Intensive Care Units in Hospitals of Ethiopia: A Multicenter Cross-Sectional Study. Open Access Emerg Med 2020; 12:435-440. [PMID: 33293877 PMCID: PMC7719042 DOI: 10.2147/oaem.s285695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/17/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Emergency drugs and essential equipment are important to successfully manage patients in the intensive care unit (ICUs). The absence of these emergency drugs and essential equipment might result in mortality and morbidity which is more compounded in resource-limited settings. This study aims to assess the availability of emergency drugs and essential equipment in ICUs in hospitals in Ethiopia. Materials and Methods A cross-sectional descriptive study design was employed in the intensive care unit of nine Amhara regional state hospitals in Ethiopia. This study was done from August 01, 2020, to September 01, 2020. The data were collected using a structured questionnaire, which were adopted from the Emergency Medicine Society of South Africa (EMSSA) guidelines. Tables and narration were used to describe results. Results There were deficiencies of essential emergency items particularly in the pediatrics domain, devices to confirm tracheal intubation and equipment for managing difficult intubation. Emergency drugs like adrenaline, salbutamol puff, atropine, aspirin, furosemide, hydrocortisone, insulin, lidocaine, and medical oxygen were available in all ICUs, whereas amiodarone, sodium bicarbonate, glucagon, ipratropium nebulization, thiamine were not available in all ICUs. Conclusions and Recommendations There were considerable deficiencies in emergency drugs and essential equipment. Based on our findings, we recommend to develop standardized checklists, regular audits, and healthcare personnel awareness program to improve checking, maintaining, restocking, and repairing the equipment in the emergency trolley.
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Affiliation(s)
- Metages Hunie
- Department of Anesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tiruwork Desse
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Efrem Fenta
- Department of Anesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Diriba Teshome
- Department of Anesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Moges Gelaw
- Department of Anesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Amanu Gashaw
- Department of Anesthesia, School of Medicine, College of Health Science, Hawassa University, Hawassa, Sidama, Ethiopia
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Hacker FM, Linkov F, Serra AE, Petticord V, Zabielski MT, Simhan HN, Sakamoto SB. Lessons Learned From a Gap Analysis of Obstetric Hemorrhage Protocols across a Health System. Matern Child Health J 2020; 25:59-65. [PMID: 33244679 DOI: 10.1007/s10995-020-03050-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The United States has experienced a rising incidence of maternal deaths, including those attributable to obstetric hemorrhage (OBH). In response, the National Partnership for Maternal Safety developed a standardized OBH Consensus Bundle with the goal of universal adoption. In 2016 a large western Pennsylvania health system adopted the OBH Consensus Bundle across its 8 obstetrical units, with the goal to improve maternal outcomes. METHODS Gap analysis was used to identify differences between existing OBH protocols and the OBH Consensus Bundle from January to June 2016. Identified gaps as well as existing practices of success were used to systematically develop and implement a standardized system-wide OBH improvement initiative. Hospitals were then categorized by annual birth volume as high (> 2000), medium (500-2000), and low (< 500) with analysis performed across these groups to identify potential trends. RESULTS All hospitals had individual successes as well as gaps that were used to direct the system-wide OBH improvement initiative. In some cases, individual plans were tailored to meet hospital resources. When hospitals were compared by annual birth volume, variation existed in their preparedness for, and management of OBH, with the single low-volume hospital having the most gaps. DISCUSSION This gap analysis identified areas for improvement among all hospitals in a health system regardless of annual birth volume. This systematic approach of evaluation of current protocols and identification of improvement targets with implementation strategies may improve maternity outcomes. Additionally, these lessons described may provide a useful framework for other hospitals and health systems as they implement their own safety bundles.
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Affiliation(s)
- Francis M Hacker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Faina Linkov
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Magee-Womens Research Institute, Pittsburgh, PA, USA.,Department of Health Administration and Public Health, Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA
| | - Allison E Serra
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Vivian Petticord
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mary T Zabielski
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Sara B Sakamoto
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Piechowski W, Clapper TC, Park JC, Ching K, St. George J. A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2020; 7:311-318. [PMID: 35515731 PMCID: PMC8936580 DOI: 10.1136/bmjstel-2020-000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 11/04/2022]
Abstract
Background There is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult-not emergency-intubation. In this study, we describe and evaluate our equipment handling unit: the AIR-BOX. Methods This is a proof-of-concept, prospective, randomised simulation trial. A convenience sample of 50 airway course participants voluntarily underwent randomisation: 21 to the AIR-BOX group, 14 to the intubation box group, and 15 to the crash cart group. The volunteers were asked to intubate a manikin using the equipment from the storage unit of their randomisation. Outcome measures included time-to-readiness, time-to-intubation, first-pass success, and subjective operator experience. Results The mean time-to-readiness was 67.2 s with the AIR-BOX, 84.6 s with the intubation box, and 115 s with the crash cart. The mean time-to-intubation was 105 s with the AIR-BOX, 127 s with the intubation box and 167 s with the crash cart. A statistically significant difference was achieved between the AIR-BOX and the crash cart. No statistically significant difference was found between the three groups with regard to first-pass success or the time between intubation readiness and intubation. Conclusions This study supports the AIR-BOX as a viable tool that can improve and simplify access to emergency intubating equipment. It also opens doors for multiple future innovations that can positively impact equipment handling practices. Future studies can focus on assessing whether applying the AIR-BOX will yield a clinically significant impact on patient outcomes.
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Affiliation(s)
- Wojciech Piechowski
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Timothy C Clapper
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Joel C Park
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Kevin Ching
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Jonathan St. George
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
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Utilization of emergency trolley in patient ward: Is not always for emergency reason. ENFERMERIA CLINICA 2020. [DOI: 10.1016/j.enfcli.2020.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Carayon P, Hoonakker P. Human Factors and Usability for Health Information Technology: Old and New Challenges. Yearb Med Inform 2019; 28:71-77. [PMID: 31419818 PMCID: PMC6697515 DOI: 10.1055/s-0039-1677907] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Despite national mandates, incentives, and other programs, the design of health information technology (IT) remains problematic and usability problems continue to be reported. This paper reviews recent literature on human factors and usability of health IT, with a specific focus on research aimed at applying human factors methods and principles to improve the actual design of health IT, its use, and associated patient and clinician outcomes. METHODS We reviewed recent literature on human factors and usability problems of health IT and research on human-centered design of health IT for clinicians and patients. RESULTS Studies continue to show usability problems of health IT experienced by multiple groups of health care professionals (e.g., physicians and nurses) as well as patients. Recent research shows that usability is influenced by both designers (e.g., IT vendors) and implementers in health care organizations, and that the application of human-centered design practices needs to be further improved and extended. We welcome emerging research on the design of health IT for teams as team-based care is increasingly implemented throughout health care. CONCLUSIONS Progress in the application of human factors methods and principles to the design of health IT is occurring, with important information provided on their actual impact on care processes and patient outcomes. Future research should examine the work of health IT designers and implementers, which would help to develop strategies for further embedding human factors engineering in IT design processes.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, USA
| | - Peter Hoonakker
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, USA
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14
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Johnson PN, Mitchell-Van Steele A, Nguyen AL, Stoffella S, Whitmore JM. Pediatric Pharmacists' Participation in Cardiopulmonary Resuscitation Events. J Pediatr Pharmacol Ther 2019; 23:502-506. [PMID: 30697139 DOI: 10.5863/1551-6776-23.6.502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Pediatric Pharmacy Advocacy Group (PPAG) understands the dilemma and varying factors that many institutions face concerning the routine participation of pharmacists in emergency resuscitation events. Acknowledging these obstacles, the PPAG encourages all institutions to strongly consider creating, adopting, and upholding policies to address pharmacists' participation in cardiopulmonary resuscitation (CPR) as evidenced by the impact pharmacist participation has shown on the reduction of hospital medication error and mortality rates in children. The PPAG advocates that pharmacists be actively involved in the institution's CPR, medical emergency team committees, and preparation of emergency drug kits and resuscitation trays. The PPAG advocates that all institutions requiring a pharmacist's participation in CPR events consider adoption of preparatory training programs. Although the PPAG does not advocate any one specific program, consideration should be taken to ensure that pharmacists are educated on the pharmacotherapy of drugs used in the CPR process, including but not limited to basic life support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support algorithms; medication preparation and administration guidelines; medication compatibility; recommended dosing for emergency medications; and familiarity with the institutional emergency cart.
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Carayon P, Wooldridge A, Hose BZ, Salwei M, Benneyan J. Challenges And Opportunities For Improving Patient Safety Through Human Factors And Systems Engineering. Health Aff (Millwood) 2018; 37:1862-1869. [PMID: 30395503 PMCID: PMC6509351 DOI: 10.1377/hlthaff.2018.0723] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite progress on patient safety since the publication of the Institute of Medicine's 1999 report, To Err Is Human, significant problems remain. Human factors and systems engineering (HF/SE) has been increasingly recognized and advocated for its value in understanding, improving, and redesigning processes for safer care, especially for complex interacting sociotechnical systems. However, broad awareness of HF/SE and its adoption into safety improvement work have been frustratingly slow. We provide an overview of HF/SE, its demonstrated value to a wide range of patient safety problems (in particular, medication safety), and challenges to its broader implementation across health care. We make a variety of recommendations to maximize the spread of HF/SE, including formal and informal education programs, greater adoption of HF/SE by health care organizations, expanded funding to foster more clinician-engineer partnerships, and coordinated national efforts to design and operationalize a system for spreading HF/SE into health care nationally.
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Affiliation(s)
- Pascale Carayon
- Pascale Carayon ( ) is a professor in the Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - Abigail Wooldridge
- Abigail Wooldridge is an assistant professor in the Department of Industrial and Enterprise Systems Engineering, University of Illinois at Urbana-Champaign
| | - Bat-Zion Hose
- Bat-Zion Hose is a PhD student in the Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - Megan Salwei
- Megan Salwei is a PhD student in the Department of Industrial and Systems Engineering, University of Wisconsin-Madison
| | - James Benneyan
- James Benneyan is a professor in the Department of Mechanical and Industrial Engineering, Northeastern University, in Boston, Massachusetts
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Milloy S, Bubric K. A Four-Stage Method for Optimizing and Standardizing a Crash Cart Configuration. IISE Trans Occup Ergon Hum Factors 2018. [DOI: 10.1080/24725838.2018.1434574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Shaunna Milloy
- Human Factors Specialist, Patient Safety Department, Alberta Health Services
| | - Katherine Bubric
- Human Factors Specialist, Patient Safety Department, Alberta Health Services
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Levkovich BJ, Bingham G, Jones D, Kirkpatrick CM, Cooper DJJ, Dooley MJ. Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review. Aust Crit Care 2018; 32:256-272. [PMID: 30005938 DOI: 10.1016/j.aucc.2018.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood. OBJECTIVES To inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs. REVIEW METHODS A scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of "rapid response system," "medical emergency team," and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management. RESULTS Thirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited. CONCLUSIONS Medications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.
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Affiliation(s)
- Bianca J Levkovich
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.
| | - Gordon Bingham
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Daryl Jones
- Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia.
| | - Carl M Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
| | - D J Jamie Cooper
- Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Michael J Dooley
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.
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López-Herce Cid J, Rodríguez Núñez A, Carrillo Álvarez Á, Zeballos Sarrato G, Martínez Fernández-Llamazares C, Calvo Macías C. Materials for the paediatric resuscitation trolley or backpack: Expert recommendations. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Jacquet GA, Hamade B, Diab KA, Sawaya R, Dagher GA, Hitti E, Bayram JD. The Emergency Department Crash Cart: A systematic review and suggested contents. World J Emerg Med 2018; 9:93-98. [PMID: 29576820 DOI: 10.5847/wjem.j.1920-8642.2018.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart (EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. METHODS The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council (ERC) guidelines for resuscitation, and the 2013 American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) 9th edition. RESULTS There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. CONCLUSION Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.
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Affiliation(s)
- Gabrielle A Jacquet
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA; Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Bachar Hamade
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karim A Diab
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
| | - Rasha Sawaya
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gilbert Abou Dagher
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eveline Hitti
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamil D Bayram
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, complexity of tasks involved, and opportunities to track processes and outcomes. This article discusses how the delivery room is a unique environment and presents examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.
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Affiliation(s)
| | - Henry C. Lee
- Department of Pediatrics, Stanford University, Stanford, CA 94305,California Perinatal Quality Care Collaborative, Stanford, CA 94305
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21
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López-Herce Cid J, Rodríguez Núñez A, Carrillo Álvarez Á, Zeballos Sarrato G, Martínez Fernández-Llamazares C, Calvo Macías C. [Materials for the paediatric resuscitation trolley or backpack: Expert recommendations]. An Pediatr (Barc) 2017; 88:173.e1-173.e7. [PMID: 28688610 DOI: 10.1016/j.anpedi.2017.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/15/2017] [Accepted: 05/25/2017] [Indexed: 11/25/2022] Open
Abstract
Cardio-respiratory arrest (CPA) is infrequent in children, but it can occur in any place and at any time. This fact means that every health care facility must always have the staff and material ready to resuscitate a child. These recommendations are the consensus of experts of the Spanish Paediatric and Neonatal Resuscitation Group on the material and medication for paediatric and neonatal resuscitation and their distribution and use. CPR trolleys and backpacks must include the essential material to quickly and efficiently perform a paediatric CPR. At least one CPR trolley must be available in every Primary Care facility, Paediatric Intensive Care Unit, Emergency Department, and Pre-hospital Emergency Areas, as well as in paediatric wards, paediatric ambulatory areas, and radiology suites. This trolley must be easily accessible and exclusively include the essential items to perform a CPR and to assist children (from newborns to adolescents) who present with a life-threatening event. Such material must be familiar to all healthcare staff and also include the needed spare parts, as well as enough drug doses. It must also be re-checked periodically. The standardisation and unification of the material and medication of paediatric CPR carts, trolleys, and backpacks, as well as the training of the personnel in their use are an essential part of the paediatric CPR.
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Affiliation(s)
- Jesús López-Herce Cid
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid. Instituto de investigación sanitaria del Hospital Gregorio Marañón. Facultad de Medicina. Universidad Complutense de Madrid. Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal. Red de Salud Maternoinfantil y del Desarrollo (RedSAMID). RETICS financiada por el PN I+D+I 2008-2011, ISCIII - Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD16/0022.
| | - Antonio Rodríguez Núñez
- Área de Pediatría, Servicio de Críticos, Intermedios y Urgencias Pediátricas. Hospital Clínico Universitario de Santiago de Compostela. Departamento de Radiología, Psiquiatría, Salud Pública, Enfermería y Medicina de la Universidad de Santiago de Compostela (USC). Grupos de Investigación CLINURSID (USC) y Soporte Vital y Simulación (Instituto de Investigación de Santiago). Instituto de Investigación de Santiago (IDIS). Red de Salud Maternoinfantil (SAMID II). RETICS financiada por el PN 2018-2011, el ISCIII- Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER) ref: RD16/0022
| | - Ángel Carrillo Álvarez
- Servicio de Cuidados Intensivos Pediátricos. Hospital General Universitario Gregorio Marañón de Madrid. Instituto de investigación sanitaria del Hospital Gregorio Marañón. Facultad de Medicina. Universidad Complutense de Madrid. Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal. Red de Salud Maternoinfantil y del Desarrollo (RedSAMID). RETICS financiada por el PN I+D+I 2008-2011, ISCIII - Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD16/0022
| | - Gonzalo Zeballos Sarrato
- Servicio de Neonatología. Hospital General Universitario Gregorio Marañón de Madrid. Instituto de investigación sanitaria del Hospital Gregorio Marañón. Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal
| | - Cecilia Martínez Fernández-Llamazares
- Servicio de Farmacia. Hospital General Universitario Gregorio Marañón de Madrid. Instituto de investigación sanitaria del Hospital Gregorio Marañón. Red de Salud Maternoinfantil y del Desarrollo (RedSAMID). RETICS financiada por el PN I+D+I 2008-2011, ISCIII - Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD16/0022
| | - Custodio Calvo Macías
- Emérito SAS. Asociado a UGC Críticos y Urgencias Pediátricas. Hospital Regional Universitario de Málaga. Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal
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Bunting RF, Groszkruger DP. From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective. J Healthc Risk Manag 2017; 35:10-23. [PMID: 26789744 DOI: 10.1002/jhrm.21205] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The publication of To Err Is Human in 2000, followed by Crossing the Quality Chasm in 2001, marked a watershed in patient safety. The Institute of Medicine (IOM) reports intensified the focus on patient safety and demanded a redesign of the healthcare system to improve quality and safety. Since publication of these reports, the focus has been on improving processes--those methods of healthcare delivery prone to failure and errors. Recently, there has been a concerted and sustained drive to add cognitive (diagnostic) errors to the focus. The recent publication of the IOM's Improving Diagnosis in Health Care has expanded the focus on patient safety and quality improvement. A new focus on diagnostic errors augments rather than replaces the previous focus. In this article, the authors offer a brief review of To Err Is Human and Crossing the Quality Chasm to lay a historical foundation. They then discuss a transition into the focus on diagnostic errors and summarize the latest recommendations from Improving Diagnosis in Health Care. This collated synthesis of 3 powerful IOM reports should guide risk managers and other healthcare personnel as they strive to improve every aspect of healthcare delivery.
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Affiliation(s)
- Robert F Bunting
- 30 years of healthcare experience and editor of the first three additions of ASHRM's CPHRM study guide
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23
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Using Human Factors Design Principles and Industrial Engineering Methods to Improve Accuracy and Speed of Drug Selection with Medication Trays. Jt Comm J Qual Patient Saf 2016; 42:473-477. [DOI: 10.1016/s1553-7250(16)42065-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Maul E, Latham B, Westgate PM. Saving Time Under Pressure: Effectiveness of Standardizing Pediatric Resuscitation Carts. Hosp Pediatr 2016; 6:67-71. [PMID: 26794403 DOI: 10.1542/hpeds.2015-0161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Resuscitation situations are high risk and high stress, and delays in care can have significant influences on outcomes. Standardization of care protocols and equipment is postulated to decrease some of the stress and risk. The objective of this study was to document increased efficiency in finding resuscitation equipment in a standardized resuscitation cart. METHODS A new standardized resuscitation cart design was created, and a multimedia education program addressing the new design was launched. A goal was set to find required equipment in <15 seconds. Five cohorts of 10 nurses were timed at finding randomly chosen items 1, 12, 49, 152, and 351 days after new cart launch. t tests were used to compare estimated acquisition times of requested items using the new cart system to the old cart system (baseline), and a separate regression analysis was used to model skill degradation. RESULTS All pairwise comparisons showed significant decreases in mean acquisition time compared with baseline. One day after launch, the mean time to find items was reduced by 46%. Mean time to find requested items was below the goal of 15 seconds 12, 49, and 152 days after launch. This effect was lost by 351 days from launch. Regression analysis predicted the time to find items would exceed 15 seconds 287 days after launch. CONCLUSIONS Standardizing the resuscitation cart design greatly reduced time to find items and was accomplished with reduced financial cost. Skill degradation did occur over time, and refresher training was required.
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Affiliation(s)
- Erich Maul
- Division of Hospital Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky;
| | - Barbara Latham
- Office of Enterprise Quality and Safety, UK HealthCare, Lexington, Kentucky; and
| | - Philip M Westgate
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, Kentucky
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Flannery AH, Parli SE. Medication Errors in Cardiopulmonary Arrest and Code-Related Situations. Am J Crit Care 2016; 25:12-20. [PMID: 26724288 DOI: 10.4037/ajcc2016190] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PubMed/MEDLINE (1966-November 2014) was searched to identify relevant published studies on the overall frequency, types, and examples of medication errors during medical emergencies involving cardiopulmonary resuscitation and related situations, and the breakdown by type of error. The overall frequency of medication errors during medical emergencies, specifically situations related to resuscitation, is highly variable. Medication errors during such emergencies, particularly cardiopulmonary resuscitation and surrounding events, are not well characterized in the literature but may be more frequent than previously thought. Depending on whether research methods included database mining, simulation, or prospective observation of clinical practice, reported occurrence of medication errors during cardiopulmonary resuscitation and surrounding events has ranged from less than 1% to 50%. Because of the chaos of the resuscitation environment, errors in prescribing, dosing, preparing, labeling, and administering drugs are prone to occur. System-based strategies, such as infusion pump policies and code cart management, as well as personal strategies exist to minimize medication errors during emergency situations.
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Affiliation(s)
- Alexander H. Flannery
- Alexander H. Flannery is a critical care pharmacist, medical intensive care unit/pulmonary, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Sara E. Parli is a critical care pharmacist, trauma/acute care surgery, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy
| | - Sara E. Parli
- Alexander H. Flannery is a critical care pharmacist, medical intensive care unit/pulmonary, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Sara E. Parli is a critical care pharmacist, trauma/acute care surgery, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy
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Xie A, Carayon P. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety. ERGONOMICS 2014; 58:33-49. [PMID: 25323570 PMCID: PMC4297241 DOI: 10.1080/00140139.2014.959070] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Healthcare systems need to be redesigned to provide care that is safe, effective and efficient, and meets the multiple needs of patients. This systematic review examines how human factors and ergonomics (HFE) is applied to redesign healthcare work systems and processes and improve quality and safety of care. We identified 12 projects representing 23 studies and addressing different physical, cognitive and organisational HFE issues in a variety of healthcare systems and care settings. Some evidence exists for the effectiveness of HFE-based healthcare system redesign in improving process and outcome measures of quality and safety of care. We assessed risk of bias in 16 studies reporting the impact of HFE-based healthcare system redesign and found varying quality across studies. Future research should further assess the impact of HFE on quality and safety of care, and clearly define the mechanisms by which HFE-based system redesign can improve quality and safety of care.
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Affiliation(s)
- Anping Xie
- Armstrong Institute for Patient Safety and Quality, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pascale Carayon
- Center for Quality and Productivity Improvement, Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
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Grundgeiger T, Harris B, Ford N, Abbey M, Sanderson PM, Venkatesh B. Emergency medical equipment storage: benefits of visual cues tested in field and simulated settings. HUMAN FACTORS 2014; 56:958-972. [PMID: 25141599 DOI: 10.1177/0018720813514605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE We tested the effectiveness of an illustrated divider ("the divider") for bedside emergency equipment drawers in an intensive care unit (ICU). In Study I, we assessed whether the divider increases completeness and standardizes the locations of emergency equipment within the drawer. In Study 2, we investigated whether the divider decreases nurses' restocking and retrieval times and decreases their workload. BACKGROUND Easy access to fully stocked emergency equipment is important during emergencies. However, inefficient equipment storage and cognitively demanding work settings might mean that drawers are incompletely stocked and access to items is slow. METHOD A pre-post-post study investigated drawer completeness and item locations before and after the introduction of the divider to 30 ICU drawers. A subsequent experiment measured item restocking time, item retrieval time, and subjective workload for nurses. RESULTS At 2 weeks and 10 weeks after the divider was introduced, the completeness of the drawer increased significantly compared with before the divider was introduced. The divider decreased the variability of the locations of the 17 items in the drawer to 16% of its original value. Study 2 showed that restocking times but not retrieval times were significantly faster with the divider present For both tasks, nurses rated their workload lower with the divider. CONCLUSIONS The divider improved the standardization and completeness of emergency equipment. In addition, restocking times and workload were decreased with the divider. APPLICATION Redesigning storage for certain equipment using human factors design principles can help to speed and standardize restocking and ease access to equipment.
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28
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Carayon P, Xie A, Kianfar S. Human factors and ergonomics as a patient safety practice. BMJ Qual Saf 2014; 23:196-205. [PMID: 23813211 PMCID: PMC3932984 DOI: 10.1136/bmjqs-2013-001812] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/25/2013] [Accepted: 06/05/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND Human factors and ergonomics (HFE) approaches to patient safety have addressed five different domains: usability of technology; human error and its role in patient safety; the role of healthcare worker performance in patient safety; system resilience; and HFE systems approaches to patient safety. METHODS A review of various HFE approaches to patient safety and studies on HFE interventions was conducted. RESULTS This paper describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains. CONCLUSIONS HFE is a core element of patient safety improvement. Therefore, every effort should be made to support HFE applications in patient safety.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial and Systems Engineering, Center for Quality and Productivity Improvement, University of Wisconsin-Madison, , Madison, Wisconsin, USA
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Rousek JB, Hallbeck MS. The ergonomics of “Code Blue” medical emergencies: a literature review. ACTA ACUST UNITED AC 2011. [DOI: 10.1080/19488300.2011.628556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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