Sociotechnical systems approach to healthcare quality and patient safety

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units

Adverse drug events (ADEs) are common in hospitals, affecting one in six child in-patients. Medication processes are complex systems. This study aimed to explore the work-as-done of medication safety in three English paediatric units using direct observation and semi-structured interviews. We found that a combination of the physical environment, traditional work systems and team norms were among the systemic barriers to medicines safety. The layout of wards discouraged teamworking and reinforced professional boundaries. Workspaces were inadequate, and interruptions were uncontrollable. A less experienced workforce undertook prescribing and verification while more experienced nurses undertook administration. Guidelines were inadequate, with actors muddling through together. Formal controls against ADEs included checking (of prescriptions and administration) and barcode administration systems, but these did not integrate into workflows. Families played an important part in the safe administration of medication and provision of information about their children but were isolated from other parts of the system.

New insights on a recurring theme: A secondary analysis of nurse turnover using the National Sample Survey of Registered Nurses

BACKGROUND

Registered nurse (RN) turnover is a recurring phenomenon that accelerated during COVID-19 and heightened concerns about contributing factors.

PURPOSE

Provide baseline RN turnover data to which pandemic and future RN workforce turnover behaviors can be compared.

METHODS

A cross-sectional, secondary analysis of RN turnover using U.S. National Sample Survey of Registered Nurses 2018 data. Responses from 41,428 RNs (weighted N = 3,092,991) across the United States were analyzed. Sociodemographic, professional, employment, and economic data and weighting techniques were used to model prepandemic RN turnover behaviors.

DISCUSSION

About 17% of the sample reported a job turnover, with 6.2% reporting internal and 10.8% reporting external turnover. The factors common across both internal and external turnover experiences included education, employment settings, and years of nursing experience.

CONCLUSIONS

Baseline RN turnover data can help employers and policymakers understand new and recurring nursing workforce trends and develop targeted actions to reduce nurse turnover.

An evidence synthesis on perioperative Handoffs: A call for balanced sociotechnical solutions

SIGNIFICANCE

Perioperative handoffs interconnect the preoperative, intraoperative, and postoperative phases underlying surgical care to maintain care continuity -yet are prone to coordination and communication failures.

OBJECTIVE

To synthesize evidence on factors affecting the safety and quality of perioperative handoff conduct and process.

MATERIALS AND METHODS

A search of PubMed, EMBASE, and CINAHL was conducted to include observational, descriptive studies of preoperative, intraoperative, and postoperative handoffs published in English language, peer-reviewed journals. Data analysis was informed by the Systems Engineering Initiative for Patient Safety (SEIPS) framework describing the relationship between the work-system, work processes, and outcomes. Study quality was assessed using the Quality Scoring System.

RESULTS

Twenty-three studies were included. Eighteen studies focused on postoperative handoffs, with one on preoperative, three on intraoperative and only one that looked at preoperative/postoperative handoffs combined. The SEIPS framework elucidated the complex inter-related factors (enablers and barriers) related to perioperative handoff safety. While some studies found that the use of standardized handoff tools and protocols and interdisciplinary teamwork were frequently-reported enablers, other studies identified the lack of structured handoff tools and protocols, poor teamwork and communication, and improper use of documentation tools were top-cited barriers affecting handoff quality. Suggestions to ensure handoff safety and quality included implementing structured handoff checklists and protocols and building interprofessional teamwork competencies for effective communication.

DISCUSSION AND CONCLUSION

Our review highlights an urgency to develop more holistic sociotechnical solutions that can create and sustain a balance between technical innovations in tools and technologies and the non-technical interventions/training needed to improve interpersonal relations and teamwork competencies - taken together, can improve the quality and safety of perioperative handoff practice.

"There Is Method to This Madness" A Qualitative Investigation of Home Medication Management by Older Adults

OBJECTIVES

This paper explores (1) the systems and processes older adults use to manage medications at home, and (2) the well-being goals of personal interest that motivate them.

METHODS

Qualitative interviews were conducted in the homes of 12 older adults in a small city in the Midwest United States. Interviews were analyzed using inductive template analysis.

RESULTS

The average age of older adults in this study was 74.2 years (SD = 10.5), 66.7% were women. The most prominent home medication management tools used were pill boxes, containers and vials, and medication lists. Routines were often aligned with activities of daily living such as teeth brushing and eating. Their medication management work occurred in contexts of other household members and budget constraints. Routines and practices were sometimes idiosyncratic adaptations and supported goals of maintaining control and decreasing vulnerability.

CONCLUSION

In developing routines for home medication management, older adults developed systems and deliberate processes to make sense of their medication experiences in the context of their home environment and based on available resources.

Stakeholder Perspectives in Anticipation of Sharing Physicians' Notes With Parents of Hospitalized Children

OBJECTIVE

Elicit stakeholder perspectives on the anticipated benefits and challenges of sharing hospital physicians' admission and daily progress notes with parents at the bedside during their child's hospitalization and identify strategies to aid implementation of inpatient note sharing.

METHODS

Five semistructured focus groups were conducted with 34 stakeholders (8 parents, 8 nurses, 5 residents, 7 hospitalists, 6 administrators) at a tertiary children's hospital from October to November 2018 to identify anticipated benefits, challenges, and implementation strategies prior to sharing inpatient physicians' notes. A facilitator guide elicited participants' perspectives about the idea of sharing notes with parents during their child's hospitalization. Three researchers used content analysis to analyze qualitative data inductively.

RESULTS

Anticipated benefits of sharing inpatient notes included: Reinforcement of information, improved parental knowledge and empowerment, enhanced parent communication and partnership with providers, and increased provider accountability and documentation quality. Expected challenges included: Increased provider workload, heightened parental confusion, distress or anxiety, impaired parent relationship with providers, and compromised note quality and purpose. Suggested implementation strategies included: Setting staff and parent expectations upfront, providing tools to support parent education, and limiting shared note content and family eligibility.

CONCLUSIONS

Stakeholders anticipated multiple benefits and drawbacks of sharing notes with parents during their child's hospital stay and made practical suggestions for ways to implement inpatient note sharing to promote these benefits and mitigate challenges. Findings will inform the design and implementation of an intervention to share notes using an inpatient portal and evaluation of its effect on child, parent, and healthcare team outcomes.

Is the 'never event' concept a useful safety management strategy in complex primary healthcare systems?

WHY IS THE AREA IMPORTANT?

A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable.

WHAT IS ALREADY KNOWN AND GAPS IN KNOWLEDGE?

We consider whether the ideal of reducing preventable harm to 'never' is better for patient safety than, for example, the goal of managing risk materializing into harm to 'as low as reasonably practicable,' which is well-established in other complex socio-technical systems and is demonstrably achievable.We reflect on the 'never event' concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care 'never event' lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II.

FUTURE AREAS FOR ADVANCING RESEARCH AND PRACTICE

Despite their rarity, if there is to be a policy focus on 'never events,' then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The 'never event' term is well intentioned but largely aspirational-however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

Using a Systems Engineering Framework to Evaluate Proton Pump Inhibitor Prescribing in Critically Ill Patients

Proton pump inhibitors (PPIs) are a risk factor for hospital-acquired Clostridium difficile infection (CDI). Much PPI use is inappropriate, and interventions to reduce PPI use, such as for stress ulcer prophylaxis in all critically ill patients, are essential to reduce CDI rates. This mixed-methods study in a combined medical-surgical intensive care unit at a tertiary academic medical center used a human factors engineering approach to understand barriers and facilitators to optimizing PPI prescribing in these patients. We performed chart review of patients for whom PPIs were prescribed to evaluate prescribing practices. Semistructured provider interviews were conducted to determine barriers and facilitators to reducing unnecessary PPI use. Emergent themes from provider interviews were classified according to the Systems Engineering Initiative for Patient Safety model. In our intensive care unit, 25% of PPI days were not clinically indicated. Barriers to optimizing PPI prescribing included inadequate provider education, lack of institutional guidelines for stress ulcer prophylaxis, and strong institutional culture favoring PPI use. Potential facilitators included increased pharmacy oversight, provider education, and embedded decision support in the electronic medical record. Interventions addressing barriers noted by front line providers are needed to reduce unnecessary PPI use, and future studies should assess the impact of such interventions on CDI rates.

The Bugs In the Virtual Clinic: Confronting Telemedicine’s Challenges Through Empathy and Support (Preprint)

Although telemedicine has been an important conduit for clinical care during the COVID-19 pandemic, not all patients have been able to meaningfully participate in this mode of health care provision. Challenges with accessing telemedicine using consumer technology can interfere with the ability of patients and clinicians to meaningfully connect and lead to significant investments in time by clinicians and their staff. In this narrative case, we identify issues related to patients’ use of technology, make comparisons between telehealth adoption and the deployment of electronic health records, and propose that building intuitive and supported digital care experiences for patients is required to make virtual care sustainable.

Understanding key factors affecting on hospital electronic health record (EHR) adoption

Introduction:

This study investigated the factors affecting the acceptance of hospital electronic health record (EHR) adoption by users based on Technology Acceptance Model3 (TAM3).

Methods:

The self-administered TAM3 questionnaire was used for data gathering. Content validity and reliability of the TAM3 questionnaire were measured. The relation between dependent, independent, and mediator variables was analyzed using multiple regression analysis.

Results:

The results from 224 users indicated that subjective norm, job relevance, output quality, voluntariness, computer experience have significant impacts on perceived usefulness. Also, perceptions of external control and computer anxiety were identified as having significant impacts on perceived ease of use. Perceived usefulness did not have a mediator role between result demonstrability and behavioral intention. Perceived ease of use was not found to be a mediating factor in the relationship between computer self- efficacy and behavioral intention, as well as perceived enjoyment.

Conclusions:

The findings of the current study, provide valuable scientific evidence for key affecting factors on hospital EHR in Iran as a developing country. Our results showed the main constructs and relationships depicted in the TAM3 were found to be applicable to assess the adoption of hospital EHR.

A quantitative assessment of the parameters of the role of receptionists in modern primary care using the work design framework

BACKGROUND

Amidst increased pressures on General Practice across England, the receptionist continues to fulfil key administrative and clinically related tasks. The need for more robust support for these key personnel to ensure they stay focussed and motivated is apparent, however, to be effective a more systematic understanding of the parameters of their work is required. Here we present a valuable insight into the tasks they fulfil, their relationship with colleagues and their organisation and their attitudes and behaviour at work collectively defined as their 'work design'.

METHODS

Our aim was to quantitatively assess the various characteristics of receptionists in primary care in England using the validated Work Design Questionnaire (WDQ) a 21 point validated questionnaire, divided into four categories: task, knowledge and social characteristics and work context with a series of sub-categories within each, disseminated online and as a postal questionnaire to 100 practices nationally.

RESULTS

Seventy participants completed the WDQ, 54 online and 16 using the postal questionnaire with the response rate for the latter being 3.1%. The WDQ suggested receptionists experience high levels of task variety, task significance and of information processing and knowledge demands, confirming the high cognitive load placed on receptionists by performing numerous yet significant tasks. Perhaps in relation to these substantial responsibilities a reliance on colleagues for support and feedback to help negotiate this workload was reported.

CONCLUSION

The evidence of our survey suggests that the role of modern GP receptionists requires an array of skills to accommodate various administrative, communicative, problem solving, and decision-making duties. There are ways in which the role might be better supported for example devising ways to separate complex tasks to avoid the errors involved with high cognitive load, providing informal feedback, and perhaps most importantly developing training programmes.

Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis

Introduction

Daily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers’ perceptions of the intervention.

Materials and methods

This was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs.

Results

We collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences.

Conclusion

Organizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.

Inpatients Sign On: An Opportunity to Engage Hospitalized Patients and Caregivers Using Inpatient Portals

BACKGROUND

Inpatient portals are online patient portals linked to electronic health records that provide hospitalized patients and caregivers secure access to real-time clinical information and tools to enhance their communication with providers and hospital experience.

OBJECTIVE

The main objective of this commentary was to provide a perspective that inpatient portals are innovative tools poised to engage patients and caregivers during hospitalization and, thus, enhance patient-centered care.

RESULTS

Inpatient portals are desired by patients and caregivers and may contribute to improved recognition of their inpatient care team, knowledge of their treatment plan and overall inpatient experience. A sociotechnical systems approach is recommended to mitigate potential unintended consequences of inpatient portal use and support effective portal design, implementation and evaluation.

CONCLUSIONS

This article highlights the potential of using inpatient portals to engage hospitalized patients and caregivers and proposes next steps to evaluate this emerging technology.

The devil is in the detail: How a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety

Many studies have highlighted the patient safety risks in intravenous medication administration, and various technological solutions have been proposed to mitigate those risks, including 'smart pumps' and closed-loop systems. Few studies describe these implementations in detail. In this article, we report on a sociotechnical investigation of a closed-loop documentation system linked with smart pumps for intravenous infusion administration on an intensive care unit. The smart pumps are 'mapped' to an electronic prescribing and medication administration system, allowing infusion rates, volumes and boluses of intravenous medication to be monitored in real time. Ethnographic observations were conducted over 37 h, including direct observation of infusion administration (n = 23 infusions), discussions with clinical staff and semi-structured interviews with intensive care unit managers (n = 2). Analysis was based on the Distributed Cognition for Teamwork (DiCoT) method to understand how information is processed across individuals, teams and technologies. We report on how the system works in context, and identify contributions and compromises to patient safety with new risks that need to be managed at bedside and intensive care unit level.

Electronic Health Record Adoption and Nurse Reports of Usability and Quality of Care: The Role of Work Environment

BACKGROUND

Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care.

OBJECTIVE

The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety.

METHODS

This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals.

RESULTS

In fully adjusted models, comprehensive EHR adoption was associated with lower odds of nurses reporting poor usability outcomes, such as dissatisfaction with the system (odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.61-0.92). The work environment was associated with all usability outcomes with nurses in better environments being less likely to report negatively. Comprehensive EHRs (OR: 0.83; 95% CI: 0.71-0.96) and better work environments (OR: 0.47; 95% CI: 0.42-0.52) were associated with lower odds of nurses reporting fair/poor quality of care, while poor patient safety grade was associated with the work environment (OR: 0.50; 95% CI: 0.46-0.54), but not EHR adoption level.

CONCLUSION

Our findings suggest that adoption of a comprehensive EHR is associated with more positive usability ratings and higher quality of care. We also found that-independent of EHR adoption level-the hospital work environment plays a significant role in how nurses evaluate EHR usability and whether EHRs have their intended effects on improving quality and safety of care.

Moving beyond static survivorship care plans: A systems engineering approach to population health management for cancer survivors

The American cancer survivor population is ever-growing, with necessary follow-up primarily accomplished in a high-touch fashion-adding to unsustainability and fragmentation of care. Given the complexities of the health care system processes needed to support survivorship, engineering approaches may best address performance deficits and facilitate the provision of patient-centered care. Such collaboration between health care and engineering is recommended for redesigning health care delivery systems. By using Systems Engineering Initiative for Patient Safety (SEIPS), a systems engineering model widely used to improve health care quality and delivery, the authors examine the work system to identify the barriers and facilitators to necessary care in the presence of a survivorship care plan and visit. Recommendations for future improvement include ensuring that care-planning processes are dynamic, clearly assigned, resilient, and integrated with electronic health record systems.

Application of the SEIPS Model to Analyze Medication Safety in a Crisis Residential Center

PURPOSE

Medication safety and error reduction has been studied in acute and long-term care settings, but little research is found in the literature regarding mental health settings. Because mental health settings are complex, medication administration is vulnerable to a variety of errors from transcription to administration. The purpose of this study was to analyze critical factors related to a mental health work system structure and processes that threaten safe medication administration practices.

BACKGROUND

The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework to analyze factors affecting medication safety. The model approach analyzes the work system concepts of technology, tasks, persons, environment, and organization to guide the collection of data.

METHODS

In the study, the Lean methodology tools were used to identify vulnerabilities in the system that could be targeted later for improvement activities. The project director completed face-to-face interviews, asked nurses to record disruptions in a log, and administered a questionnaire to nursing staff. The project director also conducted medication chart reviews and recorded medication errors using a standardized taxonomy for errors that allowed categorization of the prevalent types of medication errors.

RESULTS

Results of the study revealed disruptions during the medication process, pharmacology training needs, and documentation processes as the primary opportunities for improvement. The project engaged nurses to identify sustainable quality improvement strategies to improve patient safety.

CONCLUSION

The mental health setting carries challenges for safe medication administration practices. Through analysis of the structure, process, and outcomes of medication administration, opportunities for quality improvement and sustainable interventions were identified, including minimizing the number of distractions during medication administration, training nurses on psychotropic medications, and improving the documentation system. A task force was created to analyze the descriptive data and to establish objectives aimed at improving efficiency of the work system and care process involved in medication administration at the end of the project.

What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation

BACKGROUND

Advanced Computerized Decision Support Systems (CDSSs) assist clinicians in their decision-making process, generating recommendations based on up-to-date scientific evidence. Although this technology has the potential to improve the quality of patient care, its mere provision does not guarantee uptake: even where CDSSs are available, clinicians often fail to adopt their recommendations. This study examines the barriers and facilitators to the uptake of an evidence-based CDSS as perceived by diverse health professionals in hospitals at different stages of CDSS adoption.

METHODS

Qualitative study conducted as part of a series of randomized controlled trials of CDSSs. The sample includes two hospitals using a CDSS and two hospitals that aim to adopt a CDSS in the future. We interviewed physicians, nurses, information technology staff, and members of the boards of directors (n = 30). We used a constant comparative approach to develop a framework for guiding implementation.

RESULTS

We identified six clusters of experiences of, and attitudes towards CDSSs, which we label as "positions." The six positions represent a gradient of acquisition of control over CDSSs (from low to high) and are characterized by different types of barriers to CDSS uptake. The most severe barriers (prevalent in the first positions) include clinicians' perception that the CDSSs may reduce their professional autonomy or may be used against them in the event of medical-legal controversies. Moving towards the last positions, these barriers are substituted by technical and usability problems related to the technology interface. When all barriers are overcome, CDSSs are perceived as a working tool at the service of its users, integrating clinicians' reasoning and fostering organizational learning.

CONCLUSIONS

Barriers and facilitators to the use of CDSSs are dynamic and may exist prior to their introduction in clinical contexts; providing a static list of obstacles and facilitators, irrespective of the specific implementation phase and context, may not be sufficient or useful to facilitate uptake. Factors such as clinicians' attitudes towards scientific evidences and guidelines, the quality of inter-disciplinary relationships, and an organizational ethos of transparency and accountability need to be considered when exploring the readiness of a hospital to adopt CDSSs.

Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences

BACKGROUND

Daily bathing with chlorhexidine gluconate (CHG) of intensive care unit (ICU) patients has been shown to reduce healthcare-associated infections and colonization by multidrug resistant organisms. The objective of this project was to describe the process of daily CHG bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital.

METHODS

We conducted 26 semi-structured interviews with a convenience sample of 4 nurse managers (NMs), 13 registered nurses (RNs) and 9 health care technicians (HCTs) working in the ICU. We used qualitative content analysis to code and analyze the data. Dedoose software was used to facilitate data management and coding. Trustworthiness and scientific integrity of the data were ensured by having two authors corroborate the coding process, conducting member checks and keeping an audit trail of all the decisions made.

RESULTS

Duration of the interviews was 15 to 39 min (average = 26 min). Five steps of bathing were identified: 1) decision to give a bath; 2) ability to give a bath; 3) decision about which soap to use; 4) delegation of a bath; and 5) getting assistance to do a bath. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. The outcome was influenced by a combination of barriers and facilitators at each step. Most barriers were related to perceived workload, patient factors, and scheduling. Facilitators were mainly organizational factors such as the policy of daily CHG bathing, the consistent supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers.

CONCLUSIONS

Patient bathing in ICUs is a complex process that can be hindered and interrupted by numerous factors. The decision to use CHG soap for bathing was only one of 5 steps of bathing and was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene. Interventions that address the organizational, provider, and patient barriers to bathing could improve adherence to a daily CHG bathing protocol.

Human Milk Management Redesign: Improving Quality and Safety and Reducing Neonatal Intensive Care Unit Nurse Stress

Human milk provides superior nutritional value for infants in the neonatal intensive care unit and is the enteral feeding of choice. Our hospital used the system engineering initiative for patient safety model to evaluate the human milk management system in our neonatal intensive care unit. Nurses described the previous process in a negative way, fraught with opportunities for error, increased stress for nurses, and the need to be away from the bedside and their patients. The redesigned process improved the quality and safety of human milk management and created time for the nurses to spend with their patients.

Providers' perceived facilitators and barriers to EHR screen sharing in outpatient settings

As health care becomes more patient-centered, some scholars and policy makers propose shifting use of electronic health records (EHRs) to a tool to educate and engage patients. Physician-patient screen sharing may provide a way to achieve this. However, the barriers and facilitators that physicians experience with screen sharing are unknown. In this study, we explored providers' facilitators and barriers to using EHR as a primary care communication tool. We conducted an interview study with 14 primary care providers to discover their views on screen sharing. We used the work system model as a conceptual framework to classify emergent factors. Content analysis yielded 28 facilitators and 56 barriers to patient-centered screen sharing in primary care. We linked these to work system elements. We outline suggestions for more patient-centered EHR systems, and for provider communication training. Finally, we consider the role screen sharing might play in the development of physician-patient situation awareness.

Designing for Risk Assessment Systems for Patient Triage in Primary Health Care: A Literature Review

Background

This literature review covers original journal papers published between 2011 and 2015. These papers review the current status of research on the application of human factors and ergonomics in risk assessment systems’ design to cope with the complexity, singularity, and danger in patient triage in primary health care.

Objective

This paper presents a systematic literature review that aims to identify, analyze, and interpret the application of available evidence from human factors and ergonomics to the design of tools, devices, and work processes to support risk assessment in the context of health care.

Methods

Electronic search was performed on 7 bibliographic databases of health sciences, engineering, and computer sciences disciplines. The quality and suitability of primary studies were evaluated, and selected papers were classified according to 4 classes of outcomes.

Results

A total of 1845 papers were retrieved by the initial search, culminating in 16 selected for data extraction after the application of inclusion and exclusion criteria and quality and suitability evaluation.

Conclusions

Results point out that the study of the implications of the lack of understanding about real work performance in designing for risk assessment in health care is very specific, little explored, and mostly focused on the development of tools.

Exploring extended scope of practice in dietetics: A systems approach

AIM

The aim of this study was to explore health professionals' perceptions of an extended scope of a practice clinic, and develop a framework using a systems approach to facilitate extended scope models across various health settings.

METHODS

A qualitative investigation using semi-structured interviews with four health professionals involved in an extended scope dietitian-led gastroenterology clinic in a hospital in regional Queensland was conducted. A case study design was utilised to investigate interviewees' perceptions of the clinic. Participants were conveniently, purposively sampled. Transcript analysis involved a descriptive analytical approach. Interviewee responses were coded and categorised into themes, and investigator triangulation was used to ensure consistency between individual analyses. A secondary interpretative analysis was conducted where relationships between key themes were mapped to the Systems Engineering Initiative for Patient Safety work system model.

RESULTS

Interviewees identified various factors as vital inputs to the work system. These were categorised into the four key elements: stakeholder support, resources, planning and the dietitian. Clinic outcomes were categorised into the impact on four key groups: patients, the dietitian, the multidisciplinary team and the health system. Mapping of the relationships between inputs and outcomes resulted in an implementation framework for extended scope of practice.

CONCLUSIONS

Extended scope of practice in dietetics may provide positive outcomes for various stakeholders. However, further development of extended scope roles for dietitians requires increased advocacy and support from governments, professional bodies, training institutions and dietitians. We have developed an implementation framework which can be utilised by health professionals interested in embracing an extended scope model of care.

Patient safety skills in primary care: a national survey of GP educators

Background

Clinicians have a vital role in promoting patient safety that goes beyond their technical competence. The qualities and attributes of the safe hospital doctor have been explored but similar work within primary care is lacking. Exploring the skills and attributes of a safe GP may help to inform the development of training programmes to promote patient safety within primary care.

This study aimed to determine the views of General Practice Educational Supervisors (GPES) regarding the qualities and attributes of a safe General Practitioner (GP) and the perceived trainability of these ‘safety skills’ and to compare selected results with those generated by a previous study of hospital doctors.

Methods

This was a two-stage study comprising content validation of a safety skills questionnaire (originally developed for hospital doctors) (Stage 1) and a prospective survey of all GPES in Scotland (n = 691) (Stage 2).

Results

Stage 1: The content-validated questionnaire comprised 66 safety skills/attributes across 17 broad categories with an overall content validation index of 0.92.

Stage 2: 348 (50%) GPES completed the survey. GPES felt the skills/attributes most important to being a safe GP were honesty (93%), technical clinical skills (89%) and conscientiousness (89%). That deemed least important/relevant to being a safe GP was leadership (36%). This contrasts sharply with the views of hospital doctors in the previous study. GPES felt the most trainable safety skills/attributes were technical skills (93%), situation awareness (75%) and anticipation/preparedness (71%). The least trainable were honesty (35%), humility (33%) and patient awareness/empathy (30%). Additional safety skills identified as relevant to primary care included patient advocacy, negotiation skills, accountability/ownership and clinical intuition (‘listening to that worrying little inner voice’).

Conclusions

GPES believe a broad range of skills and attributes contribute to being a safe GP. Important but subtle differences exist between what primary care and secondary care doctors perceive as core safety attributes. Educationalists, GPs and patient safety experts should collaborate to develop and implement training in these skills to ensure that current and future GPs possess the necessary competencies to engage and lead in safety improvement efforts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-014-0206-5) contains supplementary material, which is available to authorized users.

Macroergonomics in Healthcare Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

Pilot cluster randomised controlled trial of flooring to reduce injuries from falls in wards for older people

BACKGROUND

falls disproportionately affect older people, who are at increased risk of falls and injury. This pilot study investigates shock-absorbing flooring for fall-related injuries in wards for frail older people.

METHODS

we conducted a non-blinded cluster randomised trial in eight hospitals in England between April 2010 and August 2011. Each site allocated one bay as the 'study area', which was randomised via computer to intervention (8.3-mm thick Tarkett Omnisports EXCEL) or control (2-mm standard in situ flooring). Sites had an intervention period of 1 year. Anybody admitted to the study area was eligible. The primary outcome was the fall-related injury rate. Secondary outcomes were injury severity, fall rate and adverse events.

RESULTS

during the intervention period, 226 participants were recruited to each group (219 and 223 were analysed in the intervention and control group, respectively). Of 35 falls (31 fallers) in the intervention group, 22.9% were injurious, compared with 42.4% of 33 falls (22 fallers) in the control group [injury incident rate ratio (IRR) = 0.58, 95% CI = 0.18-1.91]. There were no moderate or major injuries in the intervention group and six in the control group. The fall IRR was 1.07 (95% CI = 0.64-1.81). Staff at intervention sites raised concerns about pushing equipment, documenting one pulled back.

CONCLUSIONS

future research should assess shock-absorbing flooring with better 'push/pull' properties and explore increased faller risk. We estimate a future trial will need 33,480-52,840 person bed-days per arm.

e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach

OBJECTIVE

To characterise the safety hazards related to e-prescribing in community pharmacies.

METHODS

The sociotechnical systems framework was used to investigate the e-prescribing technology interface in community pharmacies by taking into consideration the social, technical and environmental work elements of a user's interaction with technology. This study focused specifically on aspects of the social subsystem.

STUDY DESIGN AND SETTING

The study employed a cross-sectional qualitative design and was conducted in seven community pharmacies in Wisconsin. Direct observations, think aloud protocols and group interviews were conducted with 14 pharmacists and 16 technicians, and audio recorded. Recordings were transcribed and subjected to thematic content analysis guided by the sociotechnical systems' theoretical framework.

RESULTS

Three major themes that may increase the potential for medication errors with e-prescribing were identified and described. The three themes included: (1) increased cognitive burden on pharmacy staff, such as having to memorise parts of e-prescriptions or having to perform dosage calculations mentally; (2) interruptions during the e-prescription dispensing process; and (3) communication issues with prescribers, patients and among pharmacy staff. Pharmacy staff reported these consequences of e-prescribing increased the likelihood of medication errors.

CONCLUSIONS

This study is the first of its kind to identify patient safety risks related to e-prescribing in community pharmacies using a sociotechnical systems framework. The findings shed light on potential interventions that may enhance patient safety in pharmacies and facilitate improved e-prescribing use. Future studies should confirm patient safety hazards reported and identify ways to use e-prescribing effectively and safely in community pharmacies.