Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

… imprecise communication) team cognition. … Wooldridge AR, Carayon P, Hoonakker P, et al. Team cognition in handoffs: …

Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.

Care transitions can increase the risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model, this study explored care transitions between operating rooms and inpatient critical care units and the importance of articulation work (i.e., preparation and follow-up activities related to transitions) to ensure safe transitions.

Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

Since the SEIPS (Systems Engineering Initiative for Patient Safety) conceptual model was introduced in 2006, several additional versions have been introduced. In this commentary, the authors of SEIPS 2.0 and SEIPS 3.0 present a practice-oriented SEIPS model (SEIPS 101) along with seven simple tools for use by practitioners, researchers, and others.

Preventable harm, such as diagnostic and medication errors, threaten patient safety in ambulatory care settings. This article discusses the scientific, practice, policy, and patient/family milestones necessary to accelerate progress in reducing preventable harm among outpatients and advance ambulatory safety. The authors recommend numerous key milestones, including improving measurement methods, routine monitoring of safety for improvement and learning, leveraging patient engagement, and a national patient safety center to coordinate and lead ambulatory safety efforts.   

Care transitions increase the risk of patient safety events, and pediatric patients are particularly vulnerable. This study used the Systems Engineer Initiative for Patient Safety approach to analyze care transitions, identify system barriers and solutions to guide efforts towards improving care transitions. Nine dimensions of system barriers and facilities in care transitions were identified: anticipation; ED decision making; interacting with family; physical environment; role ambiguity; staffing/resources; team cognition; technology, and; characteristics of trauma care.  Understanding these barriers and facilitators can guide future endeavors to improve care transitions.

This narrative review describes the Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models, which provide a framework for integrating human factors and ergonomics into healthcare quality and patient safety improvements. The authors propose a SEIPS 3.0 model which would include the patient journey, defined by the authors as “the spatio-temporal distribution of patients interactions with multiple care settings over time.”

… improving physician satisfaction with the technology. … Carayon P, Hoonakker P, Hundt AS, et al. Application of human factors to improve …

Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.

System and process weaknesses can hinder safe patient care. This commentary raises awareness of human factors engineering as a key opportunity for enhancing patient safety. The authors provide recommendations to drive adoption and spread of human factors strategies through targeted education, clinician–engineer partnerships, and coordinated improvement efforts.

Many institutions are encouraging patient and family engagement in safety initiatives. Prior research has shown that allowing parents to report safety concerns may help identify errors. In this study, investigators surveyed 170 parents at the time of their child's admission to the hospital to determine their desire to watch over the care provided. At discharge, parents were surveyed about medications and hand hygiene. They found that parents who wanted to watch over their child were more likely to question providers about medication use. The authors suggest that there may be additional opportunities for engaging such parents to improve safety. A past PSNet perspective discussed patient engagement and patient safety.

Family-centered rounding is a key patient engagement strategy for hospitalized children. In this cluster-randomized trial that included nearly 300 families, 2 pediatric inpatient services implemented a checklist to promote family-centered rounding and 2 services provided usual care. Through observation of video-recordings, investigators determined that teams who were given a checklist were more likely to ask families if they had questions and to read back provider orders for confirmation. Although families' perceptions of safety climate improved with checklist implementation, overall quality and safety ratings between the checklist and usual care groups were similar. This trial provides evidence that performing certain elements of the checklist, such as read back, can modestly enhance patient and family engagement.

This human factors study examined how electronic health record (EHR) implementation affected medication safety. Researchers encountered improvements in transcription, dispensing, and administration errors after EHR introduction. Several types of medication prescribing errors, including choosing the wrong drug, duplicate orders, or orders with incorrect information, increased with EHR use. This study adds to the evidence suggesting EHR implementation has mixed effects on medication safety.

Despite the demonstrated success of technology in reducing medication errors, preventable adverse drug events remain a significant source of harm to patients. Researchers analyzed data on medication safety events in 2 ICUs at a medical center and found 1622 preventable adverse drug events among 624 patients. About one third of these events were related to electronic health record use, including duplicate orders.

This systematic review sought to determine the impact of human factors engineering principles on quality and safety improvement in health care. The authors found that redesigning around human factors has been shown to improve patient safety in several different clinical settings.

This observational study found that more than half of parents of hospitalized children initiated conversations about medications during family-centered rounds. Common topics included scheduling (i.e., frequency or duration) or adverse drug reactions. These results underscore the importance of patient engagement in medication use and safety.

As the patient safety field matures, there is increasing recognition of the need to incorporate human factors engineering methods into analyzing errors and developing solutions. These methods were used to investigate the types and frequency of medication errors in two intensive care units. Although existing medication safety interventions have mainly targeted errors at individual stages of the medication management process (e.g., computerized provider order entry [CPOE] to prevent prescribing errors), this study found that in many cases, errors occurred in an interdependent fashion at multiple stages of the process. For example, incorrect transcription of an order could then lead to a medication administration error. While CPOE is likely a solution for a significant proportion of errors, this study's results indicate a need for closed-loop systems that can minimize the risk of all types of medication errors.