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Search results for "Human Factors Engineering"

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Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.

Carayon P, Wetterneck TB, Cartmill R, et al. J Patient Saf. 2017 Feb 28; [Epub ahead of print].

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.

Journal Article > Study

Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications.

Counter D, Stewart D, MacLeod J, McLay JS. Br J Clin Pharmacol. 2017;83:1515-1520.

Multicomponent compliance aids (pill boxes or medi-sets) organize patients' medications in a compartmentalized container, with one compartment for each dosing occasion. Ideally, the aid is prefilled by a pharmacist or caregiver. The aids are intended to improve medication safety and adherence for patients taking multiple medications, but this British study found that elderly patients using these systems still used inappropriate medications at high rates.

Journal Article > Study

More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?

Hignett S, Lang A, Pickup L, et al. Ergonomics. 2016 Oct 7; [Epub ahead of print].

Barriers to achieving safe, high-quality health care are well known. This study described the myriad challenges faced by the National Health Service (NHS) in its quest to provide optimal patient care. The authors suggest that the NHS lags behind other safety critical industries in applying human factors principles.

Journal Article > Study

Viewing prevention of catheter-associated urinary tract infection as a system: using systems engineering and human factors engineering in a quality improvement project in an academic medical center.

Rhee C, Phelps ME, Meyer B, Reed WG. Jt Comm J Qual Patient Saf. 2016;42:447-471.

Catheter–associated urinary tract infections (CAUTI) lead to preventable harm and cost among hospitalized patients. In this quality improvement program, principles of human factors engineering were applied to reduce CAUTI at an academic medical center. Investigators utilized systems approaches to examine the factors related to CAUTI at their institution, including how the physical layout influenced adherence to best practices. They made changes based on this assessment, such as enhancing access to catheter maintenance supplies across all hospital units. The intervention also used technology (automated electronic health record reminders) and training (asynchronous education on catheter insertion) to augment safe catheter use. This multipronged approach led to a steep reduction in CAUTI at the end of the 3-year project compared to the preintervention period. The authors suggest that their results support the use of human factors engineering to decrease health care–associated infections.

Journal Article > Study

Do work condition interventions affect quality and errors in primary care? Results from the Healthy Work Place Study.

Linzer M, Poplau S, Brown R, et al. J Gen Intern Med. 2017;32:56-61.

Burnout among clinicians is a widespread patient safety concern. This study compared usual outpatient medical care to an intervention designed to improve clinician working conditions, with the aim of reducing medical errors and enhancing performance on a bundle of care quality measures. The intervention included an assessment of clinician perceptions of working conditions and well-being followed by a locally designed quality improvement project. Each clinic designed an intervention to address the concerns that arose from the assessment. Some clinics chose to work on improving communication or team-based chronic disease management while others focused on redesigning the clinic workflow. Investigators randomized 34 clinics either to receive the intervention or to continue their usual practice and found no differences in medical error rates or care quality measures between the clinics. The authors determined that reducing clinician burnout may not necessarily enhance patient safety and conclude that longer-term, standardized improvement interventions may be needed to augment health care quality.

Journal Article > Study

An acetaminophen icon helps reduce medication decision errors in an experimental setting.

Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.

Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.

Journal Article > Study

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

Schroeder SR, Salomon MM, Galanter WL, et al. BMJ Qual Saf. 2017;26:395-407.

Look-alike and sound-alike drug names are a concerning source of confusion and medication errors. Although drug names currently undergo tests to assess their potential for confusion prior to approval, these tests have not reliably predicted real-world error rates. This study describes the development and validation of four drug name memory and perception laboratory tests. Eighty participants completed the tests and their results were analyzed against actual errors in two large outpatient pharmacy chains. The laboratory tests performed very well, demonstrating a strong association between drug name confusion errors seen during testing and those observed in real-world experience. The authors suggest that regulators and drug companies consider using these tests prior to approval of new drug names.

Journal Article > Study

Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial.

Taylor-Phillips S, Wallis MG, Jenkinson D, et al. JAMA. 2016;315:1956-1965.

Interpretation of mammograms is a repetitive task, and a vigilance decrement—decreased attention after many repetitions of the same task—could impair diagnostic accuracy. However, this large randomized trial found no evidence for vigilance decrement. Investigators also determined that radiologists were equally accurate at identifying abnormalities regardless of the order in which they reviewed the studies.

Journal Article > Study

Nursing strategies to increase medication safety in inpatient settings.

Bravo K, Cochran G, Barrett R. J Nurs Care Qual. 2016;31:335-341.

Medication administration errors are common and are often associated with interruptions. This study reviews data from a recent study on medication safety in critical access hospitals and recommends organizational strategies to improve the safety of medication administration.

Journal Article > Study

Human factors and quality improvement in the emergency department: reducing potential errors in blood collection.

Bashkin O, Caspi S, Swissa A, Amedi A, Zornano S, Stalnikowicz R. J Patient Saf. 2016 Feb 18; [Epub ahead of print].

This pre-post study found that a human factors approach improved blood collection procedures in the emergency department, which is important for preventing adverse events such as transfusion errors. This demonstrates the benefits of applying human factors engineering in patient safety efforts across health care settings.

Journal Article > Study

Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial.

Meeker D, Linder JA, Fox CR, et al. JAMA. 2016;315:562-570.

In this cluster randomized trial among 47 primary care practices, prompting clinicians to enter justifications for prescribing antibiotics in patients with antibiotic-inappropriate diagnoses or providing peer comparisons through emails decreased mean antibiotic prescribing rates compared to controls. Antibiotics are a significant source of medical care overuse and inappropriate prescriptions can lead to avoidable harms.

Journal Article > Study

Nursing assessment of continuous vital sign surveillance to improve patient safety on the medical/surgical unit.

Watkins T, Whisman L, Booker P. J Clin Nurs. 2016;25:278-281.

This before-and-after study of continuous vital sign monitoring on medical/surgical inpatient units revealed that there was no reported alert fatigue and nurses perceived improved patient safety. This suggests that continuous vital sign monitoring may be a valuable method for nurses to enhance safety in inpatient ward settings.

Journal Article > Study

Tallman lettering as a strategy for differentiation in look-alike, sound-alike drug names: the role of familiarity in differentiating drug doppelgangers.

DeHenau C, Becker MW, Bello NM, Liu S, Bix L. Appl Ergon. 2016;52:77-84.

This study found that Tallman lettering—in which specific letters in drug names are printed in capital letters to avoid being mistaken for a look-alike or sound-alike medication—led to more effective detection of changes between drugs by health care professionals and consumers. A prior WebM&M commentary discussed Tallman lettering as one strategy for improving the safety of look-alike and sound-alike medications.

Journal Article > Study

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs.

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Maben J, Griffiths P, Penfold C, et al. BMJ Qual Saf. 2016;25:241-256.

This study used robust research methods to examine the expected and unanticipated effects of moving to all single-occupancy inpatient rooms. The accompanying editorial points out that on the surface this seems like a common sense intervention likely to improve patient experience and safety. However, this study demonstrates the complex effects even seemingly straightforward interventions can create. Although two-thirds of patients preferred the single rooms, some patients felt more isolated and lonely. Staff expressed concerns about worsened visibility, surveillance, teamwork, and monitoring. In addition, staff workflows had to change significantly and their hourly walking distances increased substantially. There was no evidence that single rooms reduced infections. Although fall rates increased following the move, the researchers felt that based on the patterns and comparison to the control hospital, this may not have been attributable to the single rooms. As the editorial highlights, this study supports the importance of vigorously evaluating a range of impact measures, including quality, safety, costs, and staff and patient experiences.

Journal Article > Study

Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.

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Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. J Clin Oncol. 2015;33:3560-3567.

Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.

Journal Article > Study

The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care.

Sujan M, Spurgeon P, Cooke P. Reliab Eng Syst Saf. 2015;141:54-62.

According to this human factors study, handoff practices in emergency medicine vary depending on physicians' competing demands. The authors suggest that these dynamic trade-offs in which handoff practices are adjusted for specific situations actually enhance safety, in contrast to recent work promoting standardized handoff communication.

Journal Article > Study

Use of a human factors classification framework to identify causal factors for medication and medical device-related adverse clinical incidents.

Mitchell RJ, Williamson A, Molesworth B. Safety Sci. 2015;79:163-174.

Researchers examined a random sample of 200 medication errors and 200 medical device-related clinical incidents in Australia using a human factors framework to identify key precursor events and contributing factors. Medication errors primarily involved staff actions that led to mistakes, whereas the device incidents were often related to equipment failures.

Journal Article > Study

Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital.

Mitchell RJ, Williamson A, Molesworth B. Appl Ergon. 2016;52:185-195.

By applying a human factors engineering framework, investigators found that medical errors usually have multiple contributing factors related to both the organization and patient characteristics. This work suggests that several types of interventions will be needed to improve patient safety.

Journal Article > Study

Lack of standardisation between specialties for human factors content in postgraduate training: an analysis of specialty curricula in the UK.

Greig PR, Higham H, Vaux E. BMJ Qual Saf. 2015;24:558-560.

This study examined curricula across multiple specialties and found significant gaps in education related to team training, decision-making, and situational awareness. The authors call for standardized terminology and assessments to facilitate uniform uptake of these skills as part of medical education.

Journal Article > Study

Surgical never events and contributing human factors.

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Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;58:515-521.

Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.

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