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.

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

… barriers to use, including lack of workflow integration. … Salwei ME, Hoonakker P, Carayon P, et al. Usability of a human factors-based clinical …

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.

… by practitioners, researchers, and others. … Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual …

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.   

Patient falls are an ongoing source of preventable harm, yet mitigating the fall risk of inpatients remains challenging. Conducted across three academic medical centers, this study evaluated the impact of a fall-prevention toolkit (Fall Tailoring Interventions for Patient Safety (Fall TIPS)). The Fall TIPS toolkit supports nurses in providing tailored, fall-prevention intervention and engages patients and families in fall prevention efforts. After implementation of Fall TIPS toolkit, there was a 15% reduction in falls and a 35% reduction in falls with injuries.

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.”

In 2014, the Agency for Healthcare Research and Quality (AHRQ) began funding Patient Safety Learning Laboratories (PSLL) which use collaborative approaches to incorporate digital health tools to improve patient safety.  This research paper discusses the experiences of 12 inpatient units at one large tertiary care center after implementation of a PSLL intended to engage patients, families and the care team in identifying, assessing and reducing threats to patient safety in real time through EHR integration.  

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

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.

This retrospective review of nearly 900 incident reports related to diagnostic imaging found that the most common type of safety problem was linked to the imaging procedure. Events associated with communicating abnormal results were less common but had a higher potential to harm patients. Most events had multiple contributing factors.

Human factors engineering is being increasingly used in the design of patient safety interventions, particularly with regard to health information technology. This qualitative study examined the use of human factors and systems engineering principles within an AHRQ-funded Patient Safety Learning Laboratory that focused on implementing digital health tools to improve safety. Surveys and focus groups provided insight as to the utility of specific human factors techniques for optimizing health information technology–based interventions.

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.

As the diagnostic safety field has matured, researchers are striving to better define the diagnostic process and identify failure modes that may lead to patient harm. This study utilized human factors engineering approaches to characterize the information sources used in radiologic diagnostic imaging according to the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Most potential errors were related to person-related factors, such as inadequate communication between clinicians, rather than technological factors.

When patients and caregivers report adverse events, they may identify unique issues that other reporting systems do not capture. The authors propose adjustments to AHRQ's Common Formats for safety event reporting that allow patients and caregivers to more effectively report adverse events. An Annual Perspective emphasized the value of patient adverse event reporting in larger efforts to engage patients in their safety.

Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.