Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47:165-175.
Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.
Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16:255-258.
Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.
Overexposure to clinical alarms can contribute to burnout, errors of omission, and staff fatigue. This guideline suggests improvements for both frontline nurses and nursing leaders to enhance the management of electrocardiogram and pulse oximetry monitoring to reduce false alarms and alarm fatigue.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Hamilton-Fairley D, Coakley J, Moss F. BMC Med Edu. 2014;14:S17.
Reduced hospital staffing at night and on weekends can increase risks. This case study from the United Kingdom describes organizational changes to enhance nighttime care in in two separate hospital settings. The strategies included engaging a nurse practitioner to lead each team, standardizing care escalation and handoff practices, employing specialty teams until 9 PM, and streamlining care teams. These human factors engineering approaches resulted in high provider satisfaction, cost savings, and a reduction in adverse events.
Alarms contribute to distractions, fatigue, and lack of concentration, which can result in patient harm. This commentary examines the problem in ambulatory surgery centers and summarizes resources and recommendations currently available to help staff manage alarms in this setting.
Xu T, Wick EC, Makary MA. BMJ Qual Saf. 2016;25:311-314.
This commentary explores elements of the hospital environment that can contribute to sleep deprivation and malnutrition in patients, including care complexity, hospital census, poor communication, and noise. The authors advocate for designing more patient-centered hospital systems to prevent this type of harm.
Ardenne M, Reitnauer PG. Arzneimittel-Forschung. 1975;25:1369-79.
This special issue explores adverse events in nursing, including nurses' perceptions and attitudes towards adverse events, the effect of fatigue on shift work, and how to improve clinical decision making.
Intern J Health Care Qual Assur. 2007;20(7):555-632.
This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment, and measuring safety improvements.
This commentary reviews the use of checklists in aviation and health care, discusses specific situations in which checklists may enhance patient safety, and provides recommendations for overcoming barriers to their use.
This study was one of the first "time-motion" studies of physicians, and pioneered the application of human factors engineering and industrial principles to medical practice. The authors shadowed surgeons, who are described as "the most interesting of all mechanics," at hospitals in the United States, Canada, and Germany. Based on their observations, the authors identified the components of the work day as "necessary work," "unnecessary work," "avoidable delay," and "unavoidable delay." In order to maximize the efficiency of a typical surgical practice, they argue for standardization of surgical equipment and the hospital environment, recommend scheduled rest periods to avoid fatigue, and advocate for using technology to avoid fatigue arising from necessary work.
This review discusses the important role ergonomic and human factors should play in ensuring safe anesthetic care, drawing on literature from non-health care settings. The authors begin by discussing errors in anesthesia and the opportunities created for such errors by the inevitable nature of the job. They continue by presenting a framework for the contributing factors, which include the work environment (eg, noise, lighting, temperature), the human component (eg, team factors, fatigue, workload), and the equipment and system component (eg, alarms, automation). The authors advocate for greater attention to these contributing factors and further study based on the experiences of other high-risk, error-prone industries.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.