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The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review.

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Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. Adv Simul (Lond). 2022;7:12.

Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.

Improving Patient Safety with Human Factors Methods.

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Armstrong Institute for Patient Safety and Quality. Sept 19, 26, 30, 2022.

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.

Using Human Factors Engineering and Design Thinking to Improve Clinical Operations.

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ECRI, Thomas Jefferson University's College of Population Health, College of Health Professions, and the School of Design and Engineering. March 15, 2022; April 19, 2022; May 17, 2022. 12:30-1:30 PM (eastern).

The complexity of health care delivery requires solutions designed with daily practice workflow in mind to reduce the need for individual resilience and work-arounds to ensure safe care. This three-session workshop will examine how design thinking can be coupled with human factors engineering to reduce challenges to safety and patient-centeredness.

What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness.

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Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. J Patient Saf. 2022;17:e929-e958.

Crew resource management (CRM), originally developed in aviation, has become popular in healthcare as a method to train groups to function as teams, rather than as a collection of individuals. This review identified ambiguities in CRM definition, outcome, and information, and highlighted the need for future research to expand beyond acute care and to investigate the sustainability of lessons learned from CRM trainings.

Healthcare Systems Ergonomics and Patient Safety Triennial Conference.

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Delft University of Technology. Faculty Industrial Design Engineering. Delft, The Netherlands, November 2-4, 2022

Learning from the human factors community is a key strategy for system safety improvement. This conference, with the theme of Convergence - Breaking Down Barriers between Disciplines, will present sessions on topics such as patient safety, resilience engineering, and clinical decision making.

World Patient Safety, Science & Technology Summit.

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Patient Safety Movement Foundation. April 29-30, 2022.

Multidisciplinary educational opportunities promote cross-industry learning to improve patient safety. This virtual session will highlight high reliability organizations and patient advocacy as topics.

Curated Libraries

Medication/Drug Errors

Technology, Education and Safety.

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Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

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Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2:e075.

The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.

Prevention of failure to rescue in obstetric patients: a realist review.

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Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.

Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.

The Hidden Danger of Unseen Intravenous Catheters

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October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

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US Food and Drug Administration. October 7, 2021.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

The Safety Competencies Framework.

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Ottawa, ON: Canadian Patient Safety Institute; 2008.

This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020.

Dual surgeon operating to improve patient safety.

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Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59:752-756.

Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.

Curated Libraries

Maternal Safety

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

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

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.

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

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August 25, 2021

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

An Inadvertent Bolus of Norepinephrine.

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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.

Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities

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May 26, 2021

A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7.

Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS.

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Jt Comm J Qual Patient Saf. 2021;47:394-397.

Smart infusions pumps with built-in dose error reduction software (DERS) are designed to protect against dosing errors that result in patient harm. This alert summarizes recommendations to enhance the effective implementation and use of smart infusion pumps such as drug library maintenance and pump error report monitoring.

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