A methodology for identifying human error in U.S. Navy diving accidents

Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents

Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organization. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value. Accordingly, we developed an automated language analysis method for measuring the likelihood of patient-reported safety incidents in online patient feedback. Feedback from patients and families (n = 146,685, words = 22,191,427, years = 2013-2019) about acute NHS trusts (hospital conglomerates; n = 134) in England were analyzed. The automated measure had good precision (0.69) and excellent recall (0.98) in identifying incidents; was independent of staff-reported incidents (r = -0.04 to 0.19); and was associated with hospital-level mortality rates (z = 3.87; p < 0.001). The identified safety incidents were often reported as unnoticed (89%) or unresolved (21%), suggesting that patients use online platforms to give visibility to safety concerns they believe have been missed or ignored. Online stakeholder feedback is akin to a safety valve; being independent and unconstrained it provides an outlet for reporting safety issues that may have been unnoticed or unresolved within formal channels.

The patient's "story": an examination of patient-reported safety incidents in general practice

BACKGROUND

Patient safety incidents (PSIs) are typically studied through engagement with healthcare providers, without input from patients despite their privileged viewpoint of care experiences.

OBJECTIVES

To examine the potential of the patient viewpoint as a lens for future safety improvement initiatives, by: (i) collecting and analysing patients' accounts of PSIs; and (ii) comparing patient and clinician perceptions of PSIs.

METHODS

Firstly, Critical Incident Technique (CIT) interviews were used to obtain rich descriptions of PSIs, which were then condensed into patient stories. Deductive content analysis was used to code the safety deficiencies described in patient stories using patient-derived safety categories. Secondly, General Practitioners (GPs) and patients individually rated the perceived severity and likelihood of each story.

RESULTS

A total of 32 eligible patient stories were obtained from 25 interviews. Stories commonly described deficiencies related to communication, staff performance, and compassion/dignity/respect. There were significant differences in GP (n = 14) and patient (n = 11) severity and likelihood ratings. GPs were significantly more likely to consider stories to be a lower severity, and occurring with a lower frequency than patients.

CONCLUSION

Elicitation of the patient perspective using the CIT allowed for the rich description of safety deficiencies that occur in general practice. Given that patients bring a unique and important viewpoint on safety, there is a need to make greater efforts to include the patient perspective of safety in healthcare.

Work Content of General Practitioners in Beijing, China: A Multi-method Study

Background

Despite the dramatic growth of primary care in China, little evidence showed what general practitioner (GP) do and how GP provided medical service in Beijing.

Objective

This study aimed to explore the work content of GPs in primary care in Beijing.

Methods

A multi-method study was conducted in five community health service institutions using non-participant observation and critical incident technique interview. Eleven GPs was recruited by purpose sampling, with each GP recording details of 100 patient encounters. Health problems of patients and activities of GPs were observed in consultations. Then, critical incident technique interviews were conducted focusing on GPs' works out of clinics and challenge.

Results

A total of 1, 100 patients encounters and 1,897 reasons for encounter (RFEs) were recorded from 11 GPs. There were 1897 RFEs (1.72 per encounter) and 2,762 health problems (2.51 per encounter) from 1,100 encounters during our observation. GPs' work related to consultation was focus on disease diagnoses and treatment. Physical examination and investigations were performed in only 15.5 and 17.1% consultations, respectively. Procedures for chronic disease management were infrequently provided to patients (0.4–26.6%). Time spent in each work process in consultations ranged from 0.68 ± 0.27 min for reservation to 4.00 ± 2.45 min for surgical treatment. In addition to clinical work, there were tasks about health files, contracted family doctor services, health education, teaching students, and scientific research.

Conclusion

This study illustrated the complexity of GPs' work and heavy workload in Beijing, China. More attention and effort are needed to develop GPs performance and release GPs' work workload in primary care.

Decompression illness treated at the Geneva hyperbaric facility 2010-2016: A retrospective analysis of local cases

INTRODUCTION

The Geneva hyperbaric chamber is the main treatment centre for decompression illness (DCI) in Switzerland. The characteristics, symptomatology, treatment and short-term outcome of divers treated at this chamber have not previously been investigated.

METHODS

This was a retrospective study of patients treated with hyperbaric oxygen (HBO) for DCI from 2010 to 2016. Data were analysed to provide a description of the cases and statistical analysis for possible factors associated with an unfavourable outcome.

RESULTS

One hundred and thirty-five patients were treated for DCI. Ninety-two were included in the study. Sixty-four presented with neurological and 28 with mild DCI. One hundred and thirty-five patients were treated for DCI. Ninety-two were included in the study. Sixty-four presented with neurological and 28 with mild DCI. Patients with mild DCI mainly had musculoskeletal symptoms (79%). Patients with neurological DCI mainly had spinal (55%), followed by vestibular (36%) symptoms. Arterial gas embolism was diagnosed in 30% of cases. Diving depths ranged between 15 and 142 metres, and dive times between two and 241 min. Median time to treatment was 6 h. Patients with neurological DCI had a high rate (25%) of persisting deficits after treatment. Older age was associated with an unfavourable outcome in univariate but not in multivariate analysis. No adverse effects of HBO were observed. For spinal DCI, a high Boussuges score was associated with persisting deficits after treatment.

CONCLUSIONS

Our findings are consistent with other series. Severe DCI was associated with a high rate of persisting deficits. No single factor was associated with a negative outcome. A Boussuges score > 7 had sensitivity of 90% and positive predictive value 53% for predicting an unfavourable outcome in spinal DCI.

An analysis of general practitioners' perspectives on patient safety incidents using critical incident technique interviews

BACKGROUND

General practitioners report difficulty in knowing how to improve patient safety.

OBJECTIVES

To analyse general practitioners' perspectives of contributing factors to patient safety incidents by collecting accounts of incidents, identifying the contributory factors to these incidents, assessing the impact and likelihood of occurrence of these incidents and examining whether certain categories of contributory factors were associated with the occurrence of high-risk incidents.

METHODS

Critical incident technique interviews were carried out with 30 general practitioners in Ireland about a patient safety incident they had experienced. The Yorkshire Contributory Factors Framework was used to classify the contributory factors to incidents. Seven subject matter experts rated the impact and likelihood of occurrence of each incident.

RESULTS

A total of 26 interviews were analysed. Almost two-thirds of the patient safety incidents were rated as having a major-to-extreme impact on the patient, and over a third were judged as having at least a bimonthly likelihood of occurrence. The most commonly described active failures were 'Medication Error' (34.6%) and 'Diagnostic Error' (30.8%). 'Situational Domain' was identified as a contributory domain in all patient safety incidents. 'Communication' breakdown at both practice and other healthcare-provider interfaces (69.2%) was also a commonly cited contributory factor. There were no significant differences in the levels of risk associated with the contributory factors.

CONCLUSIONS

Critical incident technique interviews support the identification of contributory factors to patient safety incidents. There is a need to explore the use of the resulting data for quality and safety improvement in general practice.

Disturbing and distressing: a mixed methods study on the psychological impact of end of life care on junior doctors

BACKGROUND

The Irish Medical Council has identified gaps in knowledge and communications skills of new-entrant doctors in legal, ethical and practical aspects of end of life care.

AIMS

To determine the frequency with which junior doctors deal with end of life care and patient death and to evaluate the impact this has on their psychological wellbeing.

DESIGN

A questionnaire was distributed to junior doctors to determine the frequency with which the participants had managed a patient at end of life. An abbreviated Posttraumatic Stress Disorder Checklist-Civilian version was used to evaluate psychological distress. Critical incident technique interviews explored the challenges of caring for patients at end of life.

SETTING/PARTICIPANTS

A total of 110 junior doctors in two teaching hospitals in Ireland completed the questionnaire: 39 (35.5%) interns and 71 (64.5%) senior house officers. In addition, 31 interviews were carried out with interns, senior house officers and registrars.

RESULTS

The majority (81.8%) had pronounced a death with 39.4% of senior house officers doing so more than 10 times. Three quarters (75.5%) had discussed end of life with a patient's family. Of the 110 respondents that completed the posttraumatic stress disorder checklist, 11.8% screened positively for posttraumatic stress disorder. Challenges identified at interview included lack of knowledge and preparedness, difficulty communicating with family members, a lack of support and a feeling of failure.

CONCLUSIONS

Junior doctors are regularly carrying out tasks related to end of life care, resulting in high levels of psychological distress. Further training and a change in culture are required.

Human Factors in Financial Trading: An Analysis of Trading Incidents

OBJECTIVE

This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain.

BACKGROUND

Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors-related issues in operational trading incidents.

METHOD

In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data.

RESULTS

Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors-related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common.

CONCLUSION

We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents.

APPLICATION

This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy.

A mixed-methods study of the causes and impact of poor teamwork between junior doctors and nurses

OBJECTIVES

This study aimed to collect and analyse examples of poor teamwork between junior doctors and nurses; identify the teamwork failures contributing to poor team function; and ascertain if particular teamwork failures are associated with higher levels of risk to patients.

DESIGN

Critical Incident Technique interviews were carried out with junior doctors and nurses.

SETTING

Two teaching hospitals in the Republic of Ireland.

PARTICIPANTS

Junior doctors (n = 28) and nurses (n = 8) provided descriptions of scenarios of poor teamwork. The interviews were coded against a theoretical framework of healthcare team function by three psychologists and were also rated for risk to patients by four doctors and three nurses.

RESULTS

A total of 33 of the scenarios met the inclusion criteria for analysis. A total of 63.6% (21/33) of the scenarios were attributed to 'poor quality of collaboration', 42.4% (14/33) to 'poor leadership' and 48.5% (16/33) to a 'lack of coordination'. A total of 16 scenarios were classified as high risk and 17 scenarios were classified as medium risk. Significantly more of the high-risk scenarios were associated with a 'lack of a shared mental model' (62.5%, 10/16) and 'poor communication' (50.0%, 8/16) than the medium-risk scenarios (17.6%, 3/17 and 11.8%, 2/17, respectively).

CONCLUSION

Poor teamwork between junior doctors and nurses is common and places patients at considerable risk. Addressing this problem requires a well-designed complex intervention to develop the team skills of doctors and nurses and foster a clinical environment in which teamwork is supported.

STAMP-Based HRA Considering Causality Within a Sociotechnical System: A Case of Minuteman III Missile Accident

OBJECTIVE

The study contributes to human reliability analysis (HRA) by proposing a method that focuses more on human error causality within a sociotechnical system, illustrating its rationality and feasibility by using a case of the Minuteman (MM) III missile accident.

BACKGROUND

Due to the complexity and dynamics within a sociotechnical system, previous analyses of accidents involving human and organizational factors clearly demonstrated that the methods using a sequential accident model are inadequate to analyze human error within a sociotechnical system.

METHODS

System-theoretic accident model and processes (STAMP) was used to develop a universal framework of human error causal analysis. To elaborate the causal relationships and demonstrate the dynamics of human error, system dynamics (SD) modeling was conducted based on the framework.

RESULTS

A total of 41 contributing factors, categorized into four types of human error, were identified through the STAMP-based analysis. All factors are related to a broad view of sociotechnical systems, and more comprehensive than the causation presented in the accident investigation report issued officially. Recommendations regarding both technical and managerial improvement for a lower risk of the accident are proposed.

CONCLUSION

The interests of an interdisciplinary approach provide complementary support between system safety and human factors. The integrated method based on STAMP and SD model contributes to HRA effectively.

APPLICATION

The proposed method will be beneficial to HRA, risk assessment, and control of the MM III operating process, as well as other sociotechnical systems.