Systems Engineering Initiative for Patient Safety-Informed Interview Guide

Inpatient care of pediatric trauma patients includes care transitions, including from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU, which are important to patient safety and quality of care. Previous research identified work system barriers and facilitators in these transitions; the most common related to team cognition. We conducted interviews with 18 healthcare professionals to better understand how work system design influences team cognition barriers and facilitators. Using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling, we identified when each barrier/facilitator occurred. The ED to OR transition had more barriers in transition preparation, while OR to PICU had more facilitators in the transition. Future research should explore solutions to support team cognition early in the ED to OR transition, such as designing a technology to be used by distributed teams.

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Assessing information sources to elucidate diagnostic process errors in radiologic imaging — a human factors framework

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocy103 ◽

2018 ◽

Vol 25 (11) ◽

pp. 1507-1515 ◽

Cited By ~ 3

Author(s):

Laila Cochon ◽

Ronilda Lacson ◽

Aijia Wang ◽

Neena Kapoor ◽

Ivan K Ip ◽

...

Keyword(s):

Patient Safety ◽

Diagnostic Imaging ◽

Peer Review ◽

Systems Engineering ◽

Information Sources ◽

Diagnostic Process ◽

Peer Review System ◽

Review System ◽

Potential Safety ◽

Technical Factors

Abstract Objective To assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors. Materials and Methods This retrospective, Institutional Review Board-approved study was conducted at the ambulatory healthcare facilities associated with a large academic hospital. Five information sources were evaluated: an electronic safety reporting system (ESRS), alert notification for critical result (ANCR) system, picture archive and communication system (PACS)-based quality assurance (QA) tool, imaging peer-review system, and an imaging computerized physician order entry (CPOE) and scheduling system. Data from these sources (January-December 2015 for ESRS, ANCR, QA tool, and the peer-review system; January-October 2016 for the imaging ordering system) were collected to quantify the incidence of potential safety events. Reviewers classified events by the step(s) in the diagnostic process they could elucidate, and their socio-technical factors contributors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Results Potential safety events ranged from 0.5% to 62.1% of events collected from each source. Each of the information sources contributed to elucidating diagnostic process errors in various steps of the diagnostic imaging chain and contributing socio-technical factors, primarily Person, Tasks, and Tools and Technology. Discussion Various information sources can differentially inform understanding diagnostic process errors related to radiologic diagnostic imaging. Conclusion Information sources elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.

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Safe design of healthcare facilities

BMJ Quality & Safety ◽

10.1136/qshc.2006.019422 ◽

2006 ◽

Vol 15 (suppl 1) ◽

pp. i34-i40 ◽

Cited By ~ 40

Author(s):

J Reiling

Keyword(s):

Patient Safety ◽

Design Process ◽

Systems Engineering ◽

Physical Environment ◽

Community Hospital ◽

Health And Safety ◽

Facility Design ◽

Healthcare Facilities ◽

Design Recommendations ◽

Hospital Facility

The physical environment has a significant impact on health and safety; however, hospitals have not been designed with the explicit goal of enhancing patient safety through facility design. In April 2002, St Joseph’s Community Hospital of West Bend, a member of SynergyHealth, brought together leaders in healthcare and systems engineering to develop a set of safety-driven facility design recommendations and principles that would guide the design of a new hospital facility focused on patient safety. By introducing safety-driven innovations into the facility design process, environmental designers and healthcare leaders will be able to make significant contributions to patient safety.

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Patient Safety and Systems Engineering: What's Missing?

Insight ◽

10.1002/inst.201013313 ◽

2010 ◽

Vol 13 (3) ◽

pp. 13-17

Keyword(s):

Patient Safety ◽

Systems Engineering

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SU-E-T-785: Using Systems Engineering to Design HDR Skin Treatment Operation for Small Lesions to Enhance Patient Safety

Medical Physics ◽

10.1118/1.4925149 ◽

2015 ◽

Vol 42 (6Part24) ◽

pp. 3518-3518

Author(s):

C Saw ◽

M Baikadi ◽

C Peters ◽

H Brereton

Keyword(s):

Patient Safety ◽

Systems Engineering ◽

Enhance Patient Safety

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Using the Systems Engineering Initiative for Patient Safety (SEIPS) model to describe critical care nursing during the SARS‐CoV ‐2 pandemic (2020)

Nursing in Critical Care ◽

10.1111/nicc.12514 ◽

2020 ◽

Vol 25 (4) ◽

pp. 203-205 ◽

Cited By ~ 2

Author(s):

Cherry Lumley ◽

Andrew Ellis ◽

Steph Ritchings ◽

Trevor Venes ◽

Jody Ede

Keyword(s):

Critical Care ◽

Patient Safety ◽

Systems Engineering ◽

Critical Care Nursing ◽

Care Nursing

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Homes of children with medical complexity as a complex work system: outcomes associated with interactions in the physical environment

Proceedings of the Human Factors and Ergonomics Society Annual Meeting ◽

10.1177/1071181319631484 ◽

2019 ◽

Vol 63 (1) ◽

pp. 753-757

Author(s):

Nadejda Doutcheva ◽

Hannah Thomas ◽

Reid Parks ◽

Ryan Coller ◽

Nicole Werner

Keyword(s):

Patient Safety ◽

Systems Engineering ◽

Physical Environment ◽

Well Being ◽

Home Environments ◽

Children With Medical Complexity ◽

Work System ◽

Systems Research ◽

Physical Environments ◽

Medical Complexity

Family caregivers provide critical care for children with medical complexity (CMC) at home, yet homes are still a poorly understood healthcare setting. Home environments include diverse physical environments, technologies, tools, tasks, and people, and are therefore complex work systems. Research suggests that home environments can contribute positively and negatively to both individuals’ well-being and the quality of care that families can provide. Our objective for this study was to determine how the physical environment of the home interacts within a work system to affect outcomes related to in-home care of CMC. We used contextual inquiry to interview 30 caregivers in their homes and analyzed our data using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model. We focused on identifying physical environments’ interactions with other work system components and the resulting CMC outcomes. We identified six categories of outcomes that are influenced by work system interactions within the physical environment: 1) Safe or Unsafe delivery of care; 2) Prepared for or Inability to Respond to Care Crisis; 3) Home Mobility or Inaccessibility; 4) Efficient and Inefficient Care; 5) Inclusion and Isolation from Family; and 6) Socioemotional Comfort and Stress. The physical environment influences a range of outcomes from patient safety to families’ emotional well-being. Our results point to the need for adaptation of SEIPS 2.0 to the home environment by incorporating consideration for family and home-based outcomes into the model.

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Work system design for patient safety: the SEIPS model

BMJ Quality & Safety ◽

10.1136/qshc.2005.015842 ◽

2006 ◽

Vol 15 (suppl 1) ◽

pp. i50-i58 ◽

Cited By ~ 702

Author(s):

P Carayon ◽

A Schoofs Hundt ◽

B-T Karsh ◽

A P Gurses ◽

C J Alvarado ◽

...

Keyword(s):

Health Care ◽

Patient Safety ◽

System Design ◽

Systems Engineering ◽

Care Setting ◽

Outpatient Surgery ◽

Work System ◽

Advance Research

Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper we describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.

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Patient Safety in Surgical Care

DeckerMed Surgery ◽

10.2310/surg.2009 ◽

2014 ◽

Author(s):

Caprice C. Greenberg ◽

Amir Ghaferi

Keyword(s):

Health Care ◽

Patient Safety ◽

Systems Engineering ◽

Health Care Professionals ◽

Care Facility ◽

Surgical Care ◽

The United States ◽

Adverse Outcomes ◽

Patient Safety Indicators ◽

National Quality

The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety, identifies systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries. This review contains 4 figures, 7 tables, and 165 references.

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