The PSNet Collection

A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery.

Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17(6):e534-e539.

This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Why and how to approach user experience in safety-critical domains: the example of health care.

Grundgeiger T, Hurtienne J, Happel O. Hum Factors. 2020;63(5):821-832.

The usability of information technology continues to be a challenge in health care. The authors suggest that consideration of the user is critical to improving interaction with technology and thus increasing patient safety. They provide a theoretical foundation for considering user experience in healthcare.

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review.

Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30(9):739-746.

Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.

Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals

Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3(2):45-62.

Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.

Leadership: an effective human factor during COVID-19.

Dhahri AA, Refson J. BMJ Leader. 2021;Epub Aug 12.

Hierarchy and professional silos can disrupt collaboration. This commentary describes one hospital’s approach to shifting the surgical leadership role to facilitate communication and cross-organizational influence to affect quality and safety performance.

Applying Human Factors to Patient Safety, Reliability and Investigation in Healthcare SEIPS in Action.

Clinical Human Factors Group. October 19, 2021. 9:00AM - 12:00 PM (eastern).

The application of human factors and ergonomics methods to healthcare process design results in proactive failure reduction opportunities. This virtual conference will discuss the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe how this sociotechnical model supports system safety. Speakers include Pascale Carayon, Andrew Petrosoniak and Richard Holden.

System factors affecting patient safety in the OR: an analysis of safety threats and resiliency.

Adams-McGavin RC, Jung JJ, van Dalen ASHM, et al. Ann Surg. 2021;274(1):114-119.

Resilience is the process of identifying and overcoming unexpected adverse events. By reviewing video, audio, and patient physiologic data recorded during 24 laparoscopic surgeries, researchers were able to identify safety threats and resilience supports used to overcome them. Of the six category codes, (person, task, tools and technology, physical environment, organization, and external environment) most safety threats and supports were in the person category.

Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

Webster KLW, Stikes R, Bunnell L, et al. J Perinat Neonatal Nurs. 2021;35(3):258-265.

Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

Patterson ES, Rayo MF, Edworthy JR, et al. Hum Factors. 2021;Epub May 19.

Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.

Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation.

Fauer AJ. Herd. 2021;Epub Jun 26.

The physical design or layout of a clinical space can affect patient safety. This mixed-methods study of 8 ambulatory oncology offices found that the physical layout (e.g., visibility of patients during infusion) and location (i.e., proximity of infusion center to prescribers) impacted communication and patient safety. Consultation with clinicians regarding the physical environment prior to design of ambulatory oncology clinics could improve communication and therefore patient safety.

Improving Patient Safety with Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 11, 15 and 20, 2021.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

A qualitative study of what care workers do to provide patient safety at home through telecare.

Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21(1):553.

This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Developing a patient safety culture in primary dental care.

Bailey E, Dungarwalla M. Prim Dent J. 2021;10(1):89-95.

Research into patient safety culture in primary dental care remains limited. This commentary provides an overview of patient safety in dentistry and tools to develop a robust patient safety culture, including human factors and supporting second victims.

Wrong Site Surgery–Wrong Tooth Extraction.

Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.

Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses.

Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;Epub May 10.

Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.

Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation.

Leeftink AG, Visser J, de Laat JM, et al. Ergonomics. 2021:1-11.

Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes. Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare adrenal tumor led to a reduction in drug delivery and system errors, as well as increased drug adherence.

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic.

Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;Epub May 20.

Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.

An Inadvertent Bolus of Norepinephrine.

May 26, 2021

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.

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