0132 ‘Human factors’ and healthcare: A study of the impact of multi-disciplinary simulation training on patient safety and experience in the ward setting

Summary Objectives: The objective of this survey paper is to present and explain the impact of recent regulations and patient safety initiatives (EU, US and Canada) on Human Factors (HF) /Usability studies and research focusing on Health Information Technology (HIT). Methods: The authors have selected the most prominent of these recent regulations and initiatives, which rely on validated HF and usability methods and concepts and aim at enhancing the specific process of identification and prevention of technology-induced errors throughout the lifecycle of HIT. Results: The analysis highlights several points of consensus: 1) safety initiatives or regulations applicable to Medical Devices (MD) tend to extend to HIT, 2) Usability is considered a fundamental dimension of HIT safety, 3) HF/Usability methods and the overall Human Centred Design (HCD) approach are considered efficient solutions to ensure the design of safe and usable HIT. However, it appears that MD manufacturers, and a fortiori HIT designers and developers are still far from being able to routinely apply HCD to their products Discussion and conclusion: On the research side, we need to analyze manufacturers' difficulties with the application of the HCD process and imposed standards. For each given category of HIT, we need to identify the fundamental usability dimensions and design principles likely to impact patient safety independently of workplace settings or organizations. These should be described in terms of usability flaws, corresponding usage problems experienced by users and related outcomes. This approach requires good quality and well structured reporting of Human Factors / Usability research studies on HIT.

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Human Factoring Healthcare

Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care ◽

10.1177/2327857914031031 ◽

2014 ◽

Vol 3 (1) ◽

pp. 191-195 ◽

Cited By ~ 1

Author(s):

Kristen Miller ◽

Tandi Bagian ◽

Linda Williams

Keyword(s):

Patient Safety ◽

Adverse Events ◽

Human Factors ◽

Human Error ◽

System Level ◽

Department Of Veterans Affairs ◽

Just Culture ◽

Safe Patient Care ◽

The Individual ◽

The Impact

Even in a just culture, preventable or avoidable adverse events can often be attributed to a failure to follow recognized, evidence-based best practices or guidelines at the individual and/or system level. Investigations of adverse events have heightened the awareness of the need to redesign systems and processes to prevent human error. Despite the existence of considerable information about how to improve care through the application of human factors, healthcare professionals are not provided a means to ensure sufficient education in healthcare human factors and the impact on patient safety. Additionally, even when existing knowledge is taught, providers are challenged to translate and apply knowledge to affect safe patient care. The Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS) Healthcare Human Factors Modules were designed to address these challenges by combining dissemination of existing knowledge and recent research into accessible, hands-on activities that drive home human factors and patient safety competencies. These modules represent an innovative and engaging way to allow providers and administrators alike the ability to advance the shift to systems thinking through high-impact education.

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Human Factors and the Impact on Patient Safety

International Anesthesiology Clinics ◽

10.1097/aia.0000000000000234 ◽

2019 ◽

Vol 57 (3) ◽

pp. 25-34

Author(s):

R. Christopher Call ◽

Keith J. Ruskin ◽

Donna-Ann Thomas ◽

Michael F. O’Connor

Keyword(s):

Patient Safety ◽

Human Factors ◽

The Impact

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Sharing Lessons Learned to Prevent Incorrect Surgery

The American Surgeon ◽

10.1177/000313481207801138 ◽

2012 ◽

Vol 78 (11) ◽

pp. 1276-1280 ◽

Cited By ~ 8

Author(s):

Julia Neily ◽

Peter D. Mills ◽

Douglas E. Paull ◽

Lisa M. Mazzia ◽

James R. Turner ◽

...

Keyword(s):

Patient Safety ◽

Adverse Events ◽

Human Factors ◽

Lessons Learned ◽

Veterans Health ◽

Health Administration ◽

Nerve Blocks ◽

Ensure Patient Safety ◽

The Impact ◽

Wrong Site

The purpose of this report is to discuss surgical adverse event lessons learned and to recommend action. Examples of incorrect surgical adverse events managed in the Veterans Health Administration (VHA) patient safety system and results of a survey regarding the impact of the surgery lessons learned process are provided. The VHA implemented a process for sharing deidentified stories of surgical lessons learned. The cases are in-operating room selected examples from lessons learned from October 1, 2009, to June 30, 2011. Examples selected illustrate helpful human factors principles. To learn more about the awareness and impact of the lessons learned, we conducted a survey with Chiefs of Surgery in the VHA. The types of examples of adverse events include wrong eye implants, incorrect nerve blocks, and wrong site excisions of lesions. These are accompanied by human factors recommendations and change concepts such as designing the system to prevent mistakes, using differentiation, minimizing handoffs, and standardizing how information is communicated. The survey response rate was 76 per cent (88 of 132). Of those who had seen the surgical lessons learned (76% [67 of 88]), the majority (87%) reported they were valuable and 85% that they changed or reinforced patient safety behaviors in their facility as a result of surgical lessons learned. Simply having a policy will not ensure patient safety. When reviewing adverse events, human factors must be considered as a cause for error and for the failure to follow policy without assigning blame. VHA surgeons reported that the surgery lessons learned were valuable and impacted practice.

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MP036: Trauma Resuscitation Using in-situ Simulation Team Training (TRUST): a novel approach to latent safety threat identification in trauma care

CJEM ◽

10.1017/cem.2016.177 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S78-S79 ◽

Cited By ~ 2

Author(s):

A. Petrosoniak ◽

A. Gray ◽

M. Fan ◽

K. White ◽

M. McGowan ◽

...

Keyword(s):

Patient Safety ◽

Human Factors ◽

Trauma Care ◽

Trauma Team ◽

Team Training ◽

Framework Analysis ◽

In Situ Simulation ◽

Workflow System ◽

The Impact

Introduction: Resuscitation of a trauma patient requires a multidisciplinary team to perform in a dynamic, high-stakes environment. Error is ubiquitous in trauma care, often related to latent safety threats (LSTs) - previously unrecognized threats that can materialize at any time. In-situ simulation (ISS) allows a team to practice in their authentic environment while providing an opportunistic milieu to explore critical events and uncover LSTs that impact patient safety. Methods: At a Canadian Level 1 trauma centre, regular, unannounced trauma ISSs were conducted and video-recorded. A retrospective chart review of adverse events or unexpected deaths informed ISS scenario design. Each session began with a trauma team activation. The on-duty trauma team arrived in the trauma bay and provided care as they would for a real patient. Semi-structured debriefing with participant-driven LST identification and ethnographic observation occurred in real time. A framework analysis using video review was conducted by human factors experts to identify and evaluate LSTs. Feasibility was measured by the impact on ED workflow, interruptions of clinical care and participant feedback. Results: Six multidisciplinary, high-fidelity, ISS sessions were conducted and 70 multidisciplinary staff and trainees participated in at least one session. Using a framework analysis, LSTs were identified and categorized into seven themes that relate to clinical tasks, equipment, team communication, and participant workflow. LSTs were quantified and prioritized using a hazard scoring matrix. ISS was effectively implemented during both low and high patient volume situations. No critical interruptions in patient care were identified during ISS sessions and overall participant feedback was positive. Conclusion: This novel, multidisciplinary ISS trauma training program integrated risk-informed simulation cases with human factors analysis to identify LSTs. ISS offers an opportunity for an iterative review process of high-risk situations beyond the traditional morbidity and mortality rounds; rather than waiting for an actual case to generate discussion and review, we prophylactically examined critical situations and processes. Findings form a framework for recommendations about improvements in equipment, environment layout, workflow, system processes, effective team training, and ultimately patient safety.

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