Healthcare
The systemic causes of medication problems for hospitalised children
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Author Adam Sutherland, Suzanne Grant, Stephen Tomlin, Denham L Phipps, & Darren M Ashcroft |
| Abstract Medication processes are chaotic and complex, and assumed to be undertaken by specific professionals in isolation from other healthcare tasks. However tasks are delivered simultaneously and adaptively because of the complexity of healthcare provision. This study aimed to explore the systemic contributory factors to medication related problems in children’s wards using multiple qualitative methods (230 hours participant observation and 19 semi-structured interviews). There is insufficient resource available to undertake all the processes to ensure safety; decisions about medicines were made with reference to immediate problems only; parents were relied on to administer medicines to children, and; there was widespread non-compliance with interventions to improve safety because they conflicted with day-to-day work. |
Organisational Learning – Applying a Human Factors Approach to Learning from Human Factors Projects in Healthcare
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Author Eva-Maria Carman & Giulia Miles |
| Abstract Human Factors as a discipline provides the theories, methods, and tools to assess work and work systems. Likewise, these theories can be adopted to assess and support change to the way HF work is done, especially when the work environment drastically changes, as has occurred with the pandemic. This would require applying Human Factors theories and methods to the work done by Human Factors specialists themselves, to enhance their own working processes and systems. This paper describes the development and application of the Lessons Learnt Reflection Approach, a tool aimed at capturing aspects that work well at an operational level for Human Factors work within healthcare, with special consideration for the impact of the COVID-19 pandemic. This approach was developed in response to the increased awareness of the limitations that the pandemic created in the work environment and the need to modify methods in response. The CIEHF’s guidance “Achieving sustainable change: Capturing lessons from COVID-19” was used to provide the structure and fundamental basis for this approach. This paper will describe the method and application of this approach for three different human factors projects in healthcare, namely (1) understanding the work system changes for a physiotherapy department during the initial response to the pandemic, (2) supporting the procurement process for a large volume general medical device and (3) supporting simulation testing of a commercial medical product. |
Integrating Human Factors within a large NHS Trust
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Author Frances Ives & Dr Peter Isherwood |
| Abstract Achieving integration of Human Factors and Ergonomics (HFE) within a large NHS Trust is a challenging, daunting and lengthy task. Despite recognition from a number of organisations within the NHS that HFE can bring benefits to both staff and patients, integration is in its infancy. The NHS Trust considered in this paper has a long established Ergonomics service focusing on the reduction of musculoskeletal problems in staff. In addition, the recognition of non-technical skills had developed through high fidelity simulation training. The Trust aimed to bring both elements together to develop broader HFE knowledge and application. A multidisciplinary Human Factors Faculty (HFF) approach was therefore pursued to create a platform to drive the integration of HFE. Two of the main challenges faced by the HFF were improving the understanding of HFE and limited funding. The platform approach adopted by the HFF pulls in interested people from within the Trust to initiate and support a variety of HFE projects. This has enabled awareness of HFE to grow quickly within the Trust through a variety of means with minimal funding and resources. There are challenges involved with developing and sustaining a Faculty of this nature including maintaining skills, credibility, quality of work and the reliance of a large amount of good will! However, the diversity and quantity of HFE projects and conversations carried out since the inception of the HFF is testament to the impact that such a multidisciplinary platform approach can have within a large NHS Trust. |
Improving patient identification in radiography with a systems human factors approach
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Author Matthew Woodward, Rounaq Nayak & Peter McCulloch |
| Abstract Irradiation of the wrong patient or wrong site is a reportable adverse event for hospital radiology departments. This study applied a systems human factors/ergonomics (HFE) approach in an NHS trust to develop interventions across work system levels. Changes were implemented to address interruptions in radiography control rooms, to standardise identification checks and to run workshops to raise awareness of a systems approach for near miss reporting. |
Human Factors and Procurement: Lessons Learnt from a High-Value Procurement Exercise
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Author Eva-Maria Carman, Michael Johnson & Giulia Miles |
| Abstract Human Factors can inform and enhance traditional procurement processes by capturing the users’ input and considering the wider system into which the products will be implemented. Despite this, traditional procurement processes do not typically consider integrating HFE into the process in a systematic way. This paper describes the role of Human Factors in the different phases of a large procurement project and the lessons learnt for the procurement of hospital beds within one large NHS Hospital Trust. The aim of the procurement project was to determine the best solution that includes a variety of products and service contract from one supplier. A total of six different bedframes and two different types of mattress needed to be considered. The role of the HFE team was to provide advice at strategic project meetings, support the specification design, conduct an HFE evaluation of the products and ensuring a system’s perspective was considered throughout the process. Across all the product types, the HFE evaluation included 27 simulation testing sessions followed by feedback from staff on in-situ use on 23 different wards. Key lessons learnt included the value of qualitative data can add to support the decision-making process in procurement projects, the need to understand clinical needs as in this context there is no one perfect product due to the wide range of applications, and the need for HFE specialists to have a better understanding of the procurement process and their involvement across all phases of this type of project. |
Using flexible work practices to organise nursing staffing: impacts on the activity of caregivers
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Author Nicolas Canales Bravo, Adelaide Nascimento and Pierre Falzon |
| Abstract Nursing staffing is an essential component of managing human resources in hospitals. The performance of any healthcare organisation is dependent on their continuous ability to have a sufficient number of qualified workers, who must be deployed judiciously in an enabling work environment. Studies show that having adequate nursing staff has a positive influence on quality of care and on the health of caregivers. However, problems such as the shortage of nursing staff or the financial demands imposed on hospitals often constrain this possibility. The aim of this research was to explore the different types of flexible practices used to organise hospital nursing staffing and their consequences on the activity of caregivers. The study was carried out in the hospitalisation units of the Department of Neurology of a large Parisian hospital and responds to a request from the director of the department. This department suffers from a permanent shortage of caregivers, which affects the possibility of ensuring a continuous quality of care. This shortage of personnel leads the nursing managers to readjust the organisation of the teams according to the available personnel. Results aim to contribute to the reflection of decision-makers to find ways to improve the organisation of nursing staff. |
Critical care outreach: impacts of electronic observations and alerting technology
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Author Sophie Glazik |
| Abstract Information technology is an increasingly pervasive aspect of the healthcare environment, but introduction of new technology into complex systems like healthcare can create new opportunities for failure. Whilst literature on the unintended consequences of technology is extensive, less is known about the impacts it has on clinical work and patient safety. This paper reports the findings of a case study conducted at a large National Health Service (NHS) Trust in England, where electronic observations and alerting technology was introduced to replace paper charts. Using a qualitative approach, the study aimed to explore the impacts of this technology on a critical care outreach team’s performance and patient safety. Data from observation and ten semi-structured interviews with critical care outreach nurses were thematically analysed. The new technology has not only changed the way that patient observations data is recorded, displayed and viewed, it has also introduced a new mode of communication between groups of clinical staff: electronic alerts. Four main themes emerged that characterise the main changes brought about by the technology: communication, situation awareness, professional issues and workload. The relationship between aspects of these themes and patient safety was not perceived to be straightforward. |
Investigations by acute-hospital staff: AcciMaps or HFACS?
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Author Nick Woodier, Karen Whiting & Owen Bennett |
| Abstract For many years the classical approach to healthcare incident investigation has been Root Cause Analysis (RCA). However, healthcare has faced increasing criticism for failing to learn from when things go wrong and for investigations that are ineffective. There is a need to better support healthcare staff, who may have limited training and experience in investigation, to undertake more effective patient safety investigations. The authors aimed to identify an appropriate and usable patient safety investigation method for use by healthcare staff. The result of a literature review and engagement with experts led the authors to focus on the Human Factors Analysis and Classification System (HFACS) and AcciMap. Prior to evaluating the methods, HFACS was adapted to the acute hospital context by developing a coding set based on the original codes. Through workshops the authors identified a clear preference for HFACS. Its prescriptive nature appealed to investigators in that it considered all aspects of their systems and highlighted the potential contributory factors; it was felt to have face and content validity. HFACS presents a much-needed prescriptive model for investigators from varying backgrounds and experience. It is usable, appropriate, valid and reliable. The HFACS codes may require further development for different contexts, having been developed here for acute hospitals. |
Staff team perceptions of the Maltese outpatient parenteral antimicrobial therapy service
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Author Sara Jo Bugeja, Derek Stewart and Helen Vosper |
| Abstract The outpatient parenteral antimicrobial therapy (OPAT) service was developed to cater for hospitalised patients receiving antimicrobial treatment and who are stable enough to be discharged to an outpatient or home setting. The authors have used the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 as a framework for exploring OPAT performance in the Maltese context. This study investigated the perceptions of the system from the perspective of the OPAT staff. Analysis of the output from a focus group was mapped onto the SEIPS 2.0 framework in order to identify and assess how OPAT work system factors interacted to produce outcomes. Thematic analysis allowed key interactions to be explored. Four key themes were identified: the referral process, training and education, trust and service expansion. Combined with output from a future study phase exploring the patient experience, it is envisaged that these findings will assist in future intelligent redesign of the service. |
Combining Ergonomics Intervention and Transformation Leadership: How a Healthcare Group reduced its Injury Rate by Half
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Author David C CAPLE and VeeLyn TAN |
| Abstract A large healthcare provider has reduced its staff injury rates by 50% over the past 3 years. One of the key drivers of success has been the engagement of the Group CEO, board of directives and executive team’s personal commitment to lead the safety culture improvement. A multidimensional program was developed to raise staff awareness of the organization’s commitment towards addressing root causes of risk. This included increasing resources to the Health and Safety team, investing in manual handling equipment, updating the manual handling program, conducting walks with executive team and embedding safety within the organisation. |
Using human factors to enhance drug prescribing safety
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Author Joanne Carling, Gillian Janes & Dave Murray |
| Abstract Preventing harm by ensuring medications are prescribed accurately for patients on admission to hospital is a patent safety priority and one that should be achievable. A human factors systems analysis of the process of medicines reconciliation revealed some possible solutions to reducing drug prescribing errors for patients admitted to a hospital in England. Medicines reconciliation is a process that ensures the medication prescribed for adults in hospital corresponds to pre-admission. It aims to avoid errors such as unintended omissions, over prescribing, dosing errors or adverse drug reactions. Inadequate medicines reconciliation on admission is commonly identified as a major cause of patient morbidity. Poor access to patients’ regular medications lists is recognised as a particularly important factor. The System Engineering Initiative for Patient Safety model was used to analyse the barriers to effective medicines reconciliation in adults on admission. This model clearly recognises the interrelated nature of the five major aspects of work systems: people, tasks, tools and technologies, physical environment and organisational conditions. Adopting this approach enabled a broader, more effective analysis of the problem which identified some fundamental issues with the current process and barriers to effective medicines reconciliation which were otherwise unknown. The findings revealed how work system elements interact and the importance of acknowledging this when trying to resolve a problem like improving medicines reconciliation, rather than focusing on the behaviour of individuals. Dissemination of the findings and implementation of the recommendations arising from these also helped the organisation to appreciate the value of human factors in understanding human performance and enhancing safety. |
Factors Contributing to Task Success: Safety-II in the Context of Community-Based Patient Discharge
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Author Eva-Maria BURFORD, Bill BROWN, Mike FRAY and Patrick WATERSON |
| Abstract This explorative study investigated Safety-I and Safety-II elements in six focus groups with experienced staff involved in the patient discharge process from a community perspective. The elements explored included defining a good discharge, potential errors, influencing factors, weak signals, learning opportunities, and elements that assisted in achieving a successful task outcome. Key findings included identifying person-, task-, and organization-related examples that promote a good discharge. The weak signals and elements aiding success were categorised using the SEIPS 2.0 model. |
Systems approach to analysing suicide incidents in community-based mental health care
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Author Nye Canham, Gyuchan Thomas Jun, Satheesh Kumar & Fabida Noushad |
| Abstract Mental health services in the UK are now predominantly community-based, rather than inpatient-based. Managing patients with suicidal risk within the community setting is challenging and suicides from those currently using or having recently used these services do occur. More than half of the people who commit suicide have visited their doctor in the month before their death. In current practice within the UK health service, patient suicides are investigated as serious incidents and analysed using Root Cause Analysis (RCA) but this method has limitations in exploring deep system problems. This study reanalysed 41 of these RCA incident reports using Systems Theoretic Accident Modelling and Processes (STAMP). The analysis revealed the weaknesses within the system safety control structure and the themes around those control flaws. An inherent weakness in the control structure is the need to monitor the patient’s risk without constant observation and relying on the patient to report issues and adhere to their treatment plan. Patient engagement issues are a major theme with loss of control and feedback on the patient status due to their lack of willingness to engage with services and treatment options. In some cases, patients have presented at a time of crisis but then declined the crisis support or inpatient treatment offered to them. Patients new to services present a problem where decisions on their care have to be made with limited knowledge of the patient. Certain coordination and communication issues between the multidisciplinary teams and multiple services are also found. In this study, STAMP application enabled effective aggregation of multiple incident analysis and system-wide remedial action prioritisation. |
Understanding Non-Fixed Ligatures amongst Adolescents: A Human Factors and Ergonomics Approach
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Author Saydia Razak |
| Abstract The Children’s and Adolescents Mental Health Service (CAMHS) in-patient unit scoping exercise was a qualitative exploration to understand the increase in Non–Fixed Ligaturing (NFL) incidents at an NHS Mental and Community Health Trust. This exercise aimed to answer 3 questions: (1) What are the reasons behind NFL on the CAMHS unit? (2) When does NFL behaviour occur? and (3) How can staff better respond to and reduce NFL incidents? A Resilience Engineering approach by understanding safety-I (increased incidents of NFL) and extracting examples of Safety-II was combined with an insight to how work processes on the unit were carried out in line with “Work as Imagined” (policy) vs “Work as Done” (procedure). A triangulation of methods was used which consisted of analyses of incident reports, an observation of a shift, and semi-structured interviews with 9 members of staff. The highest number of incidents occurred between 16:00 and 19:59. The semi-structured interviews revealed a psychological underpinning behind NFL through the theme of the act of ligating. Seeing Work as Done (observation) resulted in an instant change of staffing. Safety-II was evident in effective workarounds such as accommodating unfamiliar staff through a succinct induction. The methods aligned with the safety management mode of guided adaptability providing a novel approach to produce usable tools and interventions in sensitive, volatile, and emotionally charged work environments. The CAMHS unit scoping exercise provides insights, implications, practical applications, and improvement opportunities to reduce and better respond to NFL across CAMHS units by adopting a HF/E approach. |
A work domain analysis of medicines management for hospitalised children
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Author Adam Sutherland, Denham L Phipps, Andrea Gill, Dr Kirsten Wolffsohn, Stephen Morris & Darren M Ashcroft |
| Abstract Previous attempts to improve medication safety for hospitalised children have been ineffective because they take limited account of the sociotechnical context in which the interventions occur. To address this problem, we used work domain analysis to examine medicines management for hospitalised children in England. The analysis was based on data from documentary analysis and from observation of healthcare staff and patients. Our findings identified features of the work system that should be taken into account when planning improvement interventions for this setting. |
Can Intersectionality Increase Active Travel in Marginalised Groups? A Literature Review
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Author Joy McKay, Katie Parnell & Katie Plant |
| Abstract Active travel, such as walking, running and cycling, are cheap, sustainable, and healthy ways to transit within in the urban environment. Many marginalised groups are either underrepresented in active travel modes or find they are limited using them in certain neighbourhoods or at certain times. These limitations lessen the accessibility of a range opportunities including those of employment, social activities and cultural experiences to a wide range of citizens. This review endeavours to recognise those barriers to active travel which affect a diverse selection of society and understand affordances which encourage use of these modes. It aims to identify solutions which may encourage active travel across a diverse community leading to an urban environment which is more equitably accessible for all. |
Improving access to Magnetic Resonance Imaging (MRI) examinations for people with disabilities
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Author Jon Mason, Joshua Fox & Kiki Veenhof |
| Abstract For people with disabilities, accessing healthcare services can be problematic, uncomfortable and potentially unsafe. Whether it is situational, temporary or permanent impairment, disability can affect everyone. When the healthcare company Philips Healthcare embarked on designing their next generation MRI machines, we, the human factors team, applied an inclusive design approach from the outset. In this paper, we will share details of a research study we conducted into how people with disability currently experience MRI. Data were collected via qualitative online interviews, with ten participants experienced disabilities from the UK. The findings showed that access to MRI radiology is an uncomfortable experience, both physically and cognitively. Accessibility issues were found throughout the process from travelling to the appointment, preparing for the scan, accessing and exiting the MRI machine. The general findings from the study are shared and recommendations for how to improve access to MRI radiology are presented. |
Imagining how intravenous insulin infusions are used in hospitals: A hierarchical task analysis
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Author Mais Iflaifel, Rosemary Lim, Clare Crowley, Kath Ryan and Francesca Greco |
| Abstract Intravenous (IV) insulin infusions are the treatment of choice to reduce elevated blood glucose (BG) levels in patients during an acute illness or a period of starvation in the UK. There are benefits to using IV insulin infusions such as reduced mortality, time spent in hospital and improved wound healing; however, there have also been problems reported with its use such as variability in insulin doses, complex preparation of insulin infusion in clinical areas, and the need for frequent monitoring. The wide range and complex interplay of factors associated with the use of IV insulin infusions have resulted in errors and, in some cases, have led to patient harm. Traditional safety approaches have focused on identifying and preventing errors and have explained safety in relation to the absence of errors. Efforts to reduce errors include implementing barriers and other protective measures, but such interventions can increase the complexity of the work system and introduce unexpected consequences. An emerging approach, called resilient health care, proposes understanding the variability in healthcare practitioners’ everyday work. One way to understand variability in work practices is to compare work-as-imagined: what people say, or think they do, with work-as-done: what people actually do in practice. This study aimed to explore how IV insulin infusions were perceived to be used (work-as-imagined) from the perspectives of different stakeholders and users using Hierarchical Task Analysis (HTA). This study is part of a wider project, for which there is a published protocol. To our knowledge, this is the first study exploring work-as-imagined in the use of IV insulin infusions using HTA in an English tertiary hospital. |
Medication Management in Community Care: Using Hierarchical Task Analysis to describe complex systems
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Author Thomas ALLITT, Esther KIRBY and Sue HIGNETT |
| Abstract This paper presents an investigation into medication management at a UK Community Healthcare Trust. Data were collected at two community in-patient facilities to review practice at the two sites against the Standard Operating Procedures for (1) Medicines Management and (2) Controlled Drugs Management for four key tasks: ordering, transportation, receipt and storage of medicines. The variances in practice were discussed with senior management with the recommendation to simplify the system with a single SOP and provision of in-house pharmacy services at both sites. |
Out-of-Hours Hospital Service: A Multi-Phased Approach to Applying a Systems Analysis
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Author Eva-Maria Carman, Giulia Miles, Steve Cantellow & Patrick Waterson |
| Abstract Healthcare needs to provide services 24 hours a day, seven days a week, 365 days a year. This includes out-of-hours from 17:00 to 09:00 weekdays, weekends and Bank Holidays. To provide this care, which has been estimated to be about 75% of the working week, dedicated out-of-hours teams have developed within the healthcare system. At one large NHS Hospital Trust, the focus of this study, the out-of-hours care is provided by the Hospital 24 service, a small team with limited resources covering a wide range of medical and surgical specialities across two large and complex hospital sites. In light of the increasing demand on this service, changes in available technology and with the numerous changes as a result of the COVID-19 pandemic, the Out-of-Hours Review aims to capture the current state of this service to determine the potential requirements for the future. This component of the Out-of-Hours Review aims to provide a high-level description of the system elements of the Hospital 24 Service. The systems analysis was compiled from three different data sources, namely a survey, data from the task management system and observation sessions. Using the SEIPS 2.0 model, high-level descriptions of the different work system components and a preliminary list of the barriers staff encounter, and facilitators staff use in this work system were generated. This analysis also identified the perspectives, system components and interactions that need to be explored in more detail in the next phase of this review. |
Healthcare Investigation Fatigue Trigger Tool
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Author Laura Pickup, Saskia Fursland, Mairi Alexander, Suzy Broadbent, Paul Davis, Kathryn Whitehill & Sian Blanchard |
| Abstract Fatigue and the implications on human performance are well recognised in the literature and many safety critical industries. This is not currently the case in healthcare, where there are no formal approaches to monitor or investigate the impact of fatigue on clinical performance and patient safety. The Healthcare Safety Investigation Branch (HSIB) was set up in 2017 and its core function is to provide independent investigations of healthcare incidents. HSIB adopts a systems approach to investigations and this paper will describe the work in progress to develop a standardised approach to consider fatigue. |
Systemic consequences of an augmented reality mobile paediatric code cart application
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Author Abigail R. Wooldridge, Widya Ramadhani, Jyotika Roychowdhury, Ashley Mitchell, Trina Croland, Keith Hanson, Elsa Melendez, Harleena Kendhari, Nadia Shaikh, Teresa Riech, Matthew Mischler, Sara Krzyzaniak, Ginger Barton, Kyle T. Formella, Zachary R. Abbott, John N. Farmer and Rebecca Ebert-Allen |
| Abstract Paediatric code carts (crash trolleys) contain equipment, tools and medication required quickly to resuscitate a child. Infrequent use of carts, as paediatric resuscitations are relatively rare, and logistical issues preventing access to stocked carts combine to decrease familiarity with cart contents, delay resuscitation efforts and potentially harm patients. A team of engineers, clinicians and educators developed an augmented reality application for smartphones to increase access to carts and familiarise clinicians with cart contents. Introducing a new technology into a sociotechnical system can have far reaching consequences in both expected and unexpected ways. Using focus groups as part of a larger evaluation project, physicians, physicians-in-training, nurses and nurse educators identified those consequences after using the application. The identified consequences included increasing access to carts, improving familiarity with cart contents, using the application as a clinical study guide, motivating learning, supporting stocking code carts, facilitating accreditation and certification, using the application to locate items during real resuscitations and not double-checking items before use during a real resuscitation. This project will inform the redesign of the application in light of those consequences and the development of the implementation strategy. Broadly, this project exposes clinicians, educators and engineers to principles of sociotechnical system design and influences the development of future educational technologies. |
Save Our Surgeons: An Ergonomics Evaluation of Laparoscopic Hysterectomy
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Author Sue HIGNETT, Esther MOSS, Diane GYI, Lisa CALKINS and Laura JONES |
| Abstract This paper presents an investigation of ergonomic issues and coping strategies during gynaecological laparoscopic surgery. Data were collected with questionnaires, postural analysis and interviews. The results suggest that work-related musculoskeletal disorders were present in almost 90% of survey respondents. The workplace factors included equipment dimensions, preference of port positioning and patient size with limited adjustability for all surgeons to perform comfortably and effectively. These findings have implications for service provision (availability of surgeons) and patient safety (human interface design). |
Paediatric Homecare Risk Management: A Functional Resonance Analysis Method Study of Incident and Risk Assessment Management
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Author Kevin Michael Hoy, Enda Fallon & Martina Kelly |
| Abstract Paediatric homecare is an advancing field of healthcare and risk management is an integral component of these services. This study is part of a larger study into integrated risk management in paediatric homecare risk management. Through interviews with nursing staff using Grounded Theory methodology, analysis of the risk management components was undertaken using Function Resonance Analysis Method (FRAM). The results indicated a clear mapping of the functionality of the process for incident reporting and the assessment of risks. Resonance was evident in several key functions allowing system changes for organisational improvements to enhance quality of care. KEYWORDS |
Challenges of remote teaching of clinical skills for medical students: A Case Study
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Author Matthew Flynn & Erin Timmoney |
| Abstract Medical student education amid the COVID-19 pandemic has proven complex. One solution is the teaching of otolaryngology clinical skills remotely using an online webinar. This case study summarizes an asynchronous, “Flipped Classroom” approach using Microsoft Teams: pre-reading, distribution of a mock marking scheme, and home participation. Ergonomic considerations included using a mobile webcam for close-ups and a swivel chair to demonstrate examinations. A hospital clinic room was used, with on-site IT equipment. Recording a session has many advantages as it yields an editable, reusable resource, but carries its own drawbacks. Through experience, we learnt to ‘close the loop’ with recording technologies, including obtaining a trial-run final session recording prior to the session proper. A co-tutor was found in our case to be invaluable, as they can troubleshoot technical problems, admit latecomers, and man discussion boards. Overall, emerging simulated pedagogies complemented current online technologies to surmount the current challenges commonly facing medical education. |
Capturing Changes in Healthcare during COVID-19 – A Physiotherapy Services Case Study
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Author Giulia Miles, Eva-Maria Burford & Laura Evans |
| Abstract During the UK’s initial response to the COVID-19 pandemic, the National Health Service witnessed drastic and rapid changes to the way work was done. Not only were changes implemented at an organisational level, but at a more local level, staff across the service adapted and developed methods of coping to keep the healthcare system functioning. As a result of this, ideas and innovations that emerged during the initial response may be helpful not only in the immediate future but also in the longer term. This study applied a systems approach to explore the changes and adaptations to work in the Physiotherapy department of a large acute trust in the UK during the initial response to COVID-19 (April 2020). Using online focus groups, the changes to the work structure, challenges and aspects that worked well were explored with 26 physiotherapy staff. The qualitative data was analysed using thematic analysis to determine the common themes across the focus groups. By utilising a systems approach, a better understanding of the effect of the changes and how they may be connected to challenges and aspects that worked well could be identified. The depiction of the work system also put into context some of the outcomes experienced at this time. Based on these results potential considerations for ‘wave 2’ were extracted and consisted of general work-system aspects and pandemic-specific aspects. |
Identifying resilience: A system safety review of trauma and orthopaedic theatres
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Author Victoria E. Wills, Andrew Seaton |
| Abstract A system safety review to assess the resilience in Trauma and Orthopaedic (T&O) theatres was conducted in response to a number of Never Events. The imminent publication of the Patient Safety Incident Response Framework (PSIRF) paved the way for an alternative to traditional serious incident investigation, proposing a systems-based approach and enabling subsequent improvements to be based on ‘work as done’, rather than ‘work as imagined’. Analysis identified opportunities for interventions that built system resilience, which were developed and tested by front line staff as part of a Quality Improvement (QI) collaborative. The approach demonstrated a practical application of the integration of systems theory, patient safety, resilience engineering and quality improvement approaches. |
Patient-maintained propofol sedation for orthopaedic surgery: patient variability in system use
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Author David Hewson, Nigel Bedforth, James Sprinks, Philip Breedon & Frank Worcester |
| Abstract In the UK, operations not requiring general anaesthesia may be carried out under sedation. This is generally provided by a doctor. As the patient is not controlling the sedation, they may often be either under or over-sedated, due to the doctor misjudging patients’ anxiety and sedation requirements. A potential solution is to allow the patient to control their own depth of sedation. We conducted a case series to examine the efficacy of patient-maintained propofol sedation for patients presenting for lower limb orthopaedic surgery under regional anaesthesia. Twenty-six patients undergoing lower limb surgery were given a handheld button to indicate their request for deepening sedation from a baseline propofol concentration of 0.5 g.ml-1 by 0.2 g.ml-1 increments to a maximum of 2.0 g.ml-1. Twelve patients chose not to press their button. The remaining 14 patients pressed the button a median (range) of 6 (1–29) times, obtaining a mean (SD) estimated effect-site blood propofol concentration of 0.91 g.ml-1 (0.34 g.ml-1). Feedback revealed that patients were satisfied with their sedation, were happy to have control over it, and would use the system again. Despite this consensus, sedation level profiles revealed variability in how patients used the system in terms of button press frequency and timing, associated with their pre-op anxiety and reaction to environmental events during the operation. Whilst this technique can be a safe and effective way of controlling sedation during these types of surgery, future research needs to consider the different ways patients interact with the system. |
Compliance with the WHO Surgical Safety Checklist: A Case Study from Birmingham Children’s Hospital
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Author Patrick WATERSON, Saleem ALI, Ingo JESTER and Jon WELLS |
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Surgeons’ ratings of an intraoperative stretch web-app: A pilot study
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Author M. Susan Hallbeck Ph.D and Bethany R. Lowndes Ph.D |
| Abstract Surgeons are reporting increased musculoskeletal disorders. Specifically, in the surgical suites at this institution, one surgeon had to permanently stop performing surgery due to work-related musculoskeletal disorders and others were in pain. It was determined that one intervention to be tested was periodic intraoperative microbreaks with exercises performed by surgeons within the sterile field. Previous research has shown self-reported improvement for the operative day when microbreaks are incorporated into the surgeon’s operating room (OR) routine. The initial work was done by having a 90-second microbreak leader in the room to lead calisthenic-type exercises that didn’t break scrub at convenient stopping points during surgery, about every 20 minutes. The surgeons and their teams loved having the microbreaks with exercises; however, their feedback was that the 20-minute period was not long enough and the exercises didn’t flow and lasted too long. From the researcher perspective, it also needed to be automated. Since tablets were password-protected and there were already networked computers in the ORs, a web-based application was created. New evidence-based stretches were created that shortened the duration while they focused on the surgeon’s primary target pain areas and an adjustable timer alert with snooze was added. This new GDPR compliant intraoperative stretch web-app was created and tested in ORs. This paper discusses the results of the internal roll-out. The free web-app is now available for dissemination. |
Evaluating compartmentalised coloured-coded trays for the organisation of anaesthetic syringes
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Author Victoria Laxton, Edward J.N. Stupple, Frances Maratos & Andrew Baird |
| Abstract This paper provides an overview of a project evaluating compartmentalised coloured-coded trays for organising and storing anaesthetic syringes. Interviews with consultant anaesthetists and an online error detection experiment to test the trays under secondary cognitive load were conducted. Findings indicated workspace organisation issues in theatre, and that the use of colour-coded compartmentalised trays could help organise the theatre workspace, enhance visual search and mitigate cognitive load. |
A Human Factors review of “the Blue Puffer” asthma reliever inhaler
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Author Deborah Stratford & Susan Whalley-Lloyd |
| Abstract The literature reports that Asthma Inhaler technique has not improved during the last forty years, despite improvement strategies focused on educating users to improve their technique and compliance. This is particularly critical for reliever inhaler users when ‘use error’ may result in a full asthma attack and possible death. This paper presents a pilot study Human Factors design review of the standard UK reliever inhaler, commonly referred to as ‘the blue puffer’. The results indicate a mismatch between ‘work as done’ and ‘work as imagined’ and that this mismatch appears to be influenced by the design of the inhaler. Conceptually it appears possible to improve the design of technical components of the inhaler system to reduce use errors and hence improve patient safety. This would require appropriate scenario and user testing, with any changes being integrated into the system as a whole. |
Unpacking Safety-II in action: Weak Signals of Potential Error in Patient Handling Tasks
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Author Eva-Maria BURFORD, Mike FRAY and Patrick WATERSON |
| Abstract As a result of a new definition of safety, whereby the focus on the ability to succeed under varying conditions is emphasised, new opportunities for assessing and improving safety are being developed. This study investigated both Safety-I and Safety-II elements using a focus group method with two expert groups in patient handling. The Safety-I and Safety-II elements investigated included potential errors, weak signals and learning opportunities arising from these situations. The weak signals that were identified were classified as originating from either an external or internal source. Potential learning opportunities to improve signal recognition were identified. |
Improving Referrals to Tertiary Care – Oxford Acute Referral System (OARS)
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Author Matthew WOODWARD, Nick DE PENNINGTON, Lauren MORGAN |
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Contextual factors influencing barriers and facilitators in paediatric trauma care transitions
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Author Abigail R. Wooldridge, Pascale Carayon, Peter Hoonakker, Bat-Zion Hose, Michelle M. Kelly,Thomas B. Brazelton, Ben Eithun, Shannon M. Dean, Jonathan E. Kohler, Joshua C. Ross, Deborah Rusy and Ayse P. Gurses |
| Abstract Care transitions, important for patient safety and quality of care, are common during inpatient care of paediatric trauma patients. Previous research has described the sociotechnical systems involved in care transitions from the emergency department to operating room, emergency department to paediatric intensive care unit and from operating room to paediatric intensive care unit, identifying work system barriers and facilitators that hinder or support work in those transition processes. However, that work did not explore how contextual factors, which vary across the transitions, influenced those barriers and facilitators. In this secondary analysis of interviews with 18 physicians, advanced practice providers, nurses and support staff, we investigated contextual factors that impact work system barriers and facilitators. We identified eight contextual factors that influenced barriers and facilitators in the three care transitions: time pressure, documentation practices, patient acuity, unknown or uncertain information, on-call staff, relationship between units, handoff organisation and organisational resources. Identifying contextual factors influencing barriers and facilitators to work could be an additional way to consider how interactions between system elements impact work. Future work should develop additional methods to explore and quantify work system interactions, as well as use the identified contextual factors to inform improvement efforts to redesign care transitions. |
A Human Factors Approach to Understanding and Designing for Infection Prevention and Control in a Neonatal Intensive Care Unit
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Author Chantal TRUDEL, Sue COBB, Kathryn MOMTAHAN, Janet BRINTNELL and Ann MITCHELL |
| Abstract Qualitative methods were used to understand infection prevention and control breaches within an existing neonatal intensive care unit and inform future design development. The study aimed to identify the main issues that health care workers experience in infection prevention and control and their relationship to the design of the environment. Methods from human-centred design such as planning, stakeholder meetings and naturalistic observation were used to document the unit, work processes, interactions, behaviours and perspectives of health care workers related to infection prevention and control. Thematic analysis was used to identify core issues, subthemes and their interrelationship to share with staff and inform recommendations. |
Assumption-Based Leading Indicators to Monitor Healthcare System Drift Towards Failures
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Author Elizabeth Wilson-Lewis & Gyuchan Thomas Jun |
| Abstract This study explores how the assumption-based leading indicator approach can be applied to monitor organisational drift of healthcare systems towards failures based on the Mid Staffordshire NHS hospital failure case. |
‘Accidental’ design in participatory simulation
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Author Abigail R. Wooldridge, Emily Heuck, Paul M. Jeziorczak and Jonathan A. Gehlbach |
| Abstract Participatory simulation involves workers in simulations to identify ergonomic challenges and inform work system (re)design efforts. It leverages benefits of both participatory ergonomic programs and simulation in activity ergonomics, but has not been applied to care transitions, inherent to paediatric trauma care and key to safe, high quality care. As part of a larger project focused on improving transitions of paediatric trauma patients from the operating room to the paediatric intensive care unit, we used participatory simulations in our analysis phase before our design phase. Simulating the work of care transitions proved challenging, as the simulated setting did not have working phones, and the physical transition required leaving and re-entering the high-fidelity space. Written and verbal information about the patient was provided to participants before the scenario – the written document inadvertently became a tool for the participants and thus an artefact for future analysis. This work represents an example of incorporating participatory simulation in the analysis phase in addition to the simulation phase of a design project, enriching the work of participants and the study itself. It also discusses some the challenges of designing scenarios for participatory simulation. Choices we make, even to support participants, could lead to accidental design. Further, this work represents an important advance in the study of care transitions and could lead to implementing our accidental design following further evaluation. |
Situation Awareness in Midwifery Practice
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Author Rachael L. Martin & Paul Bowie |
| Abstract Situation Awareness (SA) is commonly defined as “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future” (Endsley, 1995:36). From this cognitive perspective, SA is synonymous with perception or attention, and involves a continual monitoring of the status quo for changes that might require action by frontline operators (Flin et al 2008). Within the midwifery literature, “loss of situation awareness” has been cited as a contributory factor to adverse events and unwanted clinical outcomes (HSIB 2020; Knight et al 2014; RCOG 2017). This operationalisation of SA is problematic for multiple reasons which are explored in this discussion paper. The paper begins by exploring the transferability of human factors lessons between safety critical industries such as aviation and healthcare. Different theoretical perspectives on SA are evaluated, highlighting that the theoretical concept has been misapplied in midwifery, with distinct differences from Endsley’s original model in how it is defined and measured. The paper provides an overview of the difficulties in measuring SA, which limit the prospective utility of the construct. Furthermore, retrospective identification of loss of SA is value laden and subject to hindsight bias. This stands in opposition to the Human Factors systems approach where “human error” should be viewed as a symptom of systemic problems within an organisation, rather than a causal factor (Amer-Wahlin and Dekker, 2008; Shorrock and Williams 2016). This paper proposes that a more holistic perspective is required which considers the individual clinician within the context of the wider sociotechnical system, rather than focus solely on the performance of individuals. It is vital to identify the system factors which may lead to loss of situation awareness, in order to redesign the work environment to minimise patient harm and maximise safety (Singh et al 2006). Opportunity also exists for further research to investigate whether an alternative model of SA may be more appropriate for use in the healthcare context generally, and maternity care specifically, better reflecting the complex system in which clinicians work. |
Using Systems Thinking to Identify Risks in Telephone Triage: MEAD Study Findings
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Author Jill Poots, Jim Morgan, Matteo Curcuruto, Stephen Elliott, & Andrew Catto |
| Abstract This paper presents findings from a modified Macroergonomic Analysis and Design (MEAD) study aiming to identify system components and risks in a telephone triage system. Themes identified included: ‘accessibility and availability’; ‘risks on the part of the telephone triage professional’; ‘risks posed by callers’; and ‘barriers to safety incidents’. |
Human Factors evaluation of an advanced defibrillator for in-hospital cardiac arrest
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Author Lena Catharina Kerle, Dr. Sarah Atkinson & Giulia Miles |
| Abstract This research undertook a qualitative evaluation of an external Advanced Life Support defibrillator, the LIFEPAK® 20e, in one NHS trust. The study aimed to investigate the impact of system factors on the usability and safe use of a defibrillator/monitor used during adult resuscitation in a hospital setting. A systems model approach, a combination of the Systems Engineering Initiative for Patient Safety (SEIPS) model and the onion model has been used as a framework throughout the study. Merging these two models resulted in six components of the work system: People, equipment and devices, tasks and jobs, workspace, environment and organisation. A mixed methods approach has been applied to understand the complex work system and the processes around defibrillator use including expert consultation, device design evaluation, task analysis, semi-structured interviews with expert users and observations of simulation resuscitation training. A key outcome of this study is a representation of defibrillator use in the developed framework, which incorporates the interaction of factors relevant to defibrillator use on the six identified layers. The design of a defibrillator must be highly intuitive and robust for a dynamic clinical environment. Essential impact factors on the safe and efficient use of the defibrillator are non-technical skills of resuscitation providers such as teamwork, explicit task and role allocation, leadership as well as effective and open communication. |
Harnessing A Human Factors Approach to Improve Patient Safety
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Author Jenny Sutcliffe, Suzi Lomax & Jennifer Macallan |
| Abstract The interest in employing Human Factors (HF) in healthcare is increasing. The SCReaM HF and Team Resource Management (TRM) programme is aimed at raising the awareness, understanding and application of the science of HF within healthcare to help staff improve their safety and wellbeing and that of their patients. The programme is divided into three strands: rolling training, HF Projects and HF Engineering. The programme has been successfully embedded into an NHS Trust and provides a good model for how HF can be introduced and utilised within healthcare. |
Applying systems thinking to telephone triage
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Author Jill Poots, Jim Morgan, Matteo Curcuruto, Stephen Elliott & MaryAnn Ferreux |
| Abstract The NHS 111 telephone triage service is a complex sociotechnical system that likely carries specific safety risks not present in traditional face to face care. Despite apparent system safety risks, there is a paucity of research in telephone triage. This paper outlines the use of a macroergonomics approach to identify system components, their interactions and risks in telephone triage |
Novice and Experts Strategies for Understanding Complex Big Data
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Author Andreas REITER, Xianxu HOU, Genovefa KEFALIDOU, James GOULDING |
| Abstract Personal data is everywhere. Its complexity grows exponentially as more devices generate data. Understanding and making sense of complex data is fundamental as critical decisions may depend on its interpretation. In this lab-based observation study both novices and experts were exposed to complex medical information. The findings suggest that medical professionals employ different strategies from non-medics during sense-making and task completion. We discuss implications for designing new decision-making tools that support sense-making complex big data. |
Human factors and ergonomics-based work system assessment to facilitate quality improvement dissemination
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Author Anping Xie, PhD, Danielle W. Koontz, MAA, Annie Voskertchian, MPH, James C. Fackler, MD, Aaron M. Milstone, MD, MHS, and Charlotte Z. Woods-Hill, MD |
| Abstract Successful dissemination of quality improvement (QI) programs requires a proactive work system assessment (WSA). We applied a human factors and ergonomics (human factors) approach to facilitate WSA in the dissemination of a QI program for optimising blood culture use in pediatric intensive care units. Initially, we conducted an interview-based WSA to disseminate the program to two hospitals. Semi-structured face-to-face interviews guided by the Systems Engineering Initiative for Patient Safety 2.0 model were conducted with 32 clinicians to identify work system factors influencing blood culture ordering practices. The interview results were shared with the local QI teams to adapt interventions and customise implementation strategies. Following the small-scale dissemination, we further disseminated the program to a collaborative consisting of 15 hospitals. Given the number and geographic span of these hospitals, we could not conduct in-person interviews at each hospital. With limited capabilities and resources, the local QI teams could also not easily conduct their own WSA. Therefore, we devised a WSA survey based on findings from the interviews and administered it to 347 clinicians from the 15 hospitals. The survey results were summarised, shared, and discussed with individual hospitals to inform program adaptation and implementation. In addition, physician champions leading local QI teams assessed the use of the WSA survey. Both the WSA survey data and the evaluation of the WSA survey showed that the survey-based WSA tool could help participating hospitals understand their current blood culture ordering practices and identify potential barriers to implementing the program. This study highlighted the importance and challenges of doing a WSA in QI dissemination and demonstrated how a human factors based WSA could be effectively and efficiently performed in small and large scale dissemination. Future research is needed to expand the application of human factors based WSAs and develop additional tools to address other challenges of QI dissemination. |
Developing Foundation Pharmacist decision making skills: Covid-19 spotlights the need
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Author David Gibson, Dominic Furniss & Helen Vosper |
| Abstract The role of the pharmacist is changing, moving from a product focus, centred on the medicine, to a model of delivering person-centred care through the safe and effective use of medicines. This requires the development of enhanced clinical skills. It is recognised that there are significant gaps in current educational programmes, leaving novice pharmacists feeling unprepared for their transition to practice. This situation has been exacerbated by the current Covid-19 pandemic. Of the enhanced clinical skills, one of the most difficult to teach is decision making: often complex and high stakes, it is recognised as one of the hallmarks of the expert practitioner. Despite the importance of this skill in underpinning safe and effective practice, relatively little is known about how experts make such decisions, and there is little support for novices. This case study describes the development of a reflective tool, informed by naturalistic decision making and based on the aviation model of Threat and Error Management. This encourages systems thinking to help novice pharmacists cope with the complexities of decisions relating to real life patient-centred care. |
Digitalisation of HFE in Medical Product Development: Challenges and Opportunities
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Author Diego Cortez & Erin Davis |
| Abstract This paper presents current challenges of applying human factors engineering (HFE) throughout medical device development, and the opportunity digitalisation creates for innovation in the field. The paper focuses on describing current HFE challenges and examples of how digital tools and software applications can contribute to the work of HF specialists in the medical industry, noting that there is large, unmet need for more HF expertise. Finally, it briefly presents a case study of a software released by Emergo by UL Solutions which aims to address some of these challenges. |
“We Are a Team” Older Patients’ and Carers’ Shared Views of Hospital Information
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Author Bernadette Douglas, Sharon Cook and Sue Hignett |
| Abstract Health care providers who view patients and carers as a care partnership during hospital treatment will offer better care experiences, however, this is not always the case. Carers have reported experiences where they are not included in information and communication of their loved one’s care. This study aims to explore information seeking, communication and information access requirements and priorities of older persons and carers during hospital engagements from the perspective of “we are a team”. |
Defining Activities of Daily Living for the Design of Dementia Care Environments
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Author Charlotte JAIS, Sue HIGNETT, Martin HABELL, Adonika BROWN and Eef HOGERVORST |
| Abstract Activities of daily living (ADLs) are an important part of dementia care due to their impact on quality of life. This study looked at perceptions of ADLs in the context of designing dementia care environments through an online questionnaire targeted at design professionals and healthcare workers. Participants suggested that certain activities such as physical activity and social interaction, which go beyond the traditional definition of ADLs, are also highly important considerations in the design of dementia care homes. The results suggest that current definitions of ADLs may be too restrictive. This has implications for care practice and care home design. |
Upscaling Frontline Improvement in Surgery
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Author Lorna FLYNN, Matthew WOODWARD, Lauren MORGAN, Lance HOLMAN, Christopher PENNELL, Helen HIGHAM and Peter MCCULLOCH |
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Building a New Hospital: the role of Human Factors
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Author Lauren Morgan, David Higgins & Sue Deakin |
| Abstract The HF approach places all stakeholders at the heart of any project to identify their needs and ensure these are being met, ultimately to optimise efficiency and safety. With regards to building a new hospital, this includes not only patients’ needs, but also those of hospital staff, support workers, volunteers, and patients’ contacts. This paper discusses the approaches taken, and benefits realised |
Intensive care unit referrals: making decisions
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Author Marta Weronika Wronikowska, Verity Westgate, Jody Ede, James Malycha, Lauren Morgan & Peter Watkinson |
| Abstract Referral to an Intensive Care Unit (ICU) is a complex medical process. The decision making involved can be cognitively challenging and subjective. We aimed to identify variables used by clinicians to make decisions during the ICU referral process, define the requirements for cognitive decision making and to detect commonly repeated errors. Applied Cognitive Task Analysis (ACTA) interviews were carried out with 17 doctors and nurses of varying specialties and levels of seniority to create a high-level task analysis of the participant’s role in the ICU referral process. Interviews were audio recorded, transcribed and analysed by two researchers in NVivo 11 software. We identified 188 variables used for clinical decision-making during an ICU referral. Removal of duplicates created 30 discrete variables. We found that there was not one key variable or piece of information that was significant to clinicians. Instead a ‘big picture’ approach was described, where all the data about a single patient was assembled and cognitively processed. ‘Often missed’ factors in the referral process were also identified. The most common was failure to consult family to discern patient wishes. The 30 variables used in the ICU referral process will inform the development of an interface for the Hospital Alerting Via Electronic Noticeboard project. This aims to identify patients at risk of deterioration in hospitals. Patient wishes were often neglected during the process and mechanisms to address this will form part of future work. We propose the addition of ‘F’ for ‘functional status/family’ to the ‘ABCDE’ acronym that is commonly used to evaluate a patient’s condition. |
Team situational awareness: practitioner-centred design of a safety huddles toolkit
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Author William GREEN, Ceri JONES, John MALTBY, Simon ROBINSON, Damian ROLAND and Carol STAFFORD |
| Abstract Patients die every year because of failure to recognize early warnings of deterioration. A contributing factor is poor team communication and situational awareness. This paper describes the practitioner-centred design of a safety huddles toolkit. Interviews, observations and collective discussions conducted synchronously (face-face) and asynchronously (virtually) informed decisions to iteratively design the toolkit. The toolkit is designed for continuous adaptation to allow practitioner-led improvement for different clinical specialties. Indicative findings (from 50 teams adopting the toolkit) suggest practitioners find it useful for adopting safety huddles and improving team communication and patient awareness. The adoption of the toolkit has been extended 6 months after project completion. |
Socio-technical analysis and modeling of hazards related to test ordering and results management systems in primary care: impacts on safety and performance
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Author Paul BOWIE and Julie PRICE |
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Human Factors Integration (HFI) in UK Healthcare: a route map for 1 year, 5 years, 10 years and 20 years
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Author Sue HIGNETT, Will TUTTON, Kerry TATLOCK |
| Abstract This paper reflects on Human Factors Integration (HFI) to consider how Human Factors/Ergonomics has influenced Defence activities, and could influence safety and performance in Healthcare activities. A workshop with 16 Chartered Institute of Ergonomics & Human Factors members was held in July 2016 to discuss and propose a Route Map for HFI in the UK National Health Service. The results set out achievable targets for 1, 5, 10 and 20 years culminating in mandatory HFI to achieve a resilient system for safety culture and work load. |
Translating complex system analysis into a story-based film for participatory design: Dilemmas in suicide prevention
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Author Gyuchan Thomas Jun and I. Cecilia Landa-Avila |
| Abstract It has been widely recognised that whole systems approaches are required, but underexplored in the design and development of complex healthcare systems. Human factors and ergonomics (human factors) has adopted and developed various conceptual models and frameworks in order to support the application of systems approaches such as Cognitive Work Analysis (CWA), Systems Engineering Intitiative for Patient Safety (SEIPS), STAMP and FRAM to name but a few. Application of these systems approaches benefit from the involvement of all relevant stakeholders and the inclusion of their input in system design. However, evidence also suggests that involving healthcare stakeholders is challenging mainly due to their lack of time and system expertise. Undertanding outputs of system analysis, usually in the form of complex system maps, tends to require time and certain level of visual learning capacity, which some people don’t have. The full potential of a participatory systems approach has been hardly realised, so there is a need for improving the way the outputs of systems approaches are communicated. This study, therefore, aims to translate the outputs of complex system analysis into a story-based film for participatory design. |
Can the NHS learn about human factors from the Ministry of Defence?
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Author Giulia Miles & Sue Hignett |
| Abstract The National Health Service (NHS) in England has ambitious plans to drive innovation in health information technology (HIT) to improve patient safety, quality and cost effectiveness. Acute trusts are complex socio-technical systems that are required to implement a number of large information technology projects in order to meet national targets for digital maturity. This research explored whether the Ministry of Defence (MOD) Human Factors Integration Model for the acquisition process could be applied to a HIT project. A qualitative research study was undertaken in a large English NHS acute trust using the experience of implementing an electronic observation system to explore transferability of the MOD approach to acute healthcare. Data were collected using semi-structured interviews and focus groups and analysed thematically with reference to SEIPS 2.0 (Holden et al, 2013) healthcare systems model and the MOD framework. Key findings included limited awareness of Human Factors in healthcare; information system design/specification to deliver positive outcomes around patient safety and financial savings. Human Factors negative systems issues included alert fatigue, changing mental models, inability to maximise data for patient benefit, system resilience, local and national interoperability issues. |
Promoting ergonomics and human factors to improve transfusion safety in the UK
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Author Nicola Swarbrick, Jennifer Davies, Emma Milser, Alison Watt, Debbi Poles & Shruthi Narayan |
| Abstract Effective incident investigation is an integral part of the provision of a safe blood transfusion service, with the aim to prevent recurrence of adverse events and harm to patients. Determining how an incident has taken place allows understanding of the gaps or failures within the system and identification of effective corrective and preventive measures that can be implemented to reduce risk of recurrence. Consideration of human factors supports a more sophisticated understanding of the factors that cause incidents, optimising human performance through better understanding of human behaviour and the factors that influence this behaviour, thus improving patient safety. |
Organisational pitfalls of individual incentive innovation systems
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Author Kasper Edwards and Christine Ipsen |
| Abstract Employee-driven changes are thought to result in sustainable work that balances organisational performance and employee wellbeing. Explicating in-house knowledge about problems and potential solutions aligns the direction of change with employees’ knowledge of what is needed, and professional insight. Consequently, employees support the identified changes and welcome their implementation, increasing wellbeing at work and improving work practices. Individual incentive innovation systems (IIISs) are a particular example of employees driving change. In IIISs the organisation incentivises innovation by providing benefits to the individual who champions an innovation. IIIS shortcuts the organisational structure and hierarchy and motivates frontline employees to submit innovation proposals on their own. A Wealth of Ideas (WoI) was an individual incentive innovation system at a large Danish University Hospital. The project idea was generated and was funded by top management and would allow ten employees with the best innovation ideas to work for six months full time on their idea and be educated in innovation at the same time. The purpose of the project was to engage employees across all functions and seniority to submit ideas to introduce new, or improve existing procedures and practices in the hospital. An unforeseen effect of the project was that the ten employees seemed to be alienated by their original employer because their ideas were not aligned with their department. Moreover, the WoI had the effect that the ten employees were removed from their wards and the wards experienced a de facto loss of competence and resources, though they were compensated. The winning projects were instructed by the WoI and hospital top management that they should implement their innovations in daily practices and structures. Again, the departments experienced a loss of resources as the person returned but was ordered to work on something else, causing further alienation. |
Factors Influencing the Development of Effective Error Management Competencies in Undergraduate UK Pharmacy Students
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Author Helen VOSPER and Sue HIGNETT |
| Abstract Patient safety (PS) is a key healthcare goal, yet health professionals struggle to acquire appropriate expertise, including Human Factors/Ergonomics skills, reflected in undergraduate curricula content. More than 50% of adverse events are medicines-related, yet focus on pharmacists as experts in medicines is scant. This pilot investigation used focus groups and interviews to explore undergraduate PS teaching in purposively-selected UK pharmacy schools. Results revealed barriers to PS teaching including risk-averse pharmacist ‘personality’ and Educational Standards negatively influencing students’ error-management behaviours. |
Digital deterioration monitoring tools in care homes
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Author Tara Marshall & Amy Dolben |
| Abstract This paper uses thematic analysis to explore the effectiveness of using a digital platform to support the use of deterioration monitoring tools in care homes across Suffolk and Essex. The benefits to staff, residents and the wider healthcare landscape are numerous, but significant system-level challenges must be addressed in order to ensure the successful adoption and spread of these tools across the social care sector. |
An Insight into Patient Usability Preferences for Injection Devices
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Author Natalie SHORTT |
| Abstract There is little early-stage usability research into the factors that drive patient preference for injection device design. This study aimed to gain insight into patient preferences and underlying drivers in relation to the user-interface for self-injection devices. 128 patients across the US and UK answered dichotomous questions and gave reasons for each choice. An inductive analysis was performed; clear trends emerged in the data, which could aid in heuristic analysis and usability goals for injection device design concepts. |
Benefits of Using Simulation to Enhance Learning from Serious Incident Reporting
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Author Joanne CARLING, Tom CAIRNS, Dave MURRAY, Birgit HANUSCH, Graham BONE, Maureen TIERNAN, Karen DONNELLY, Gina WATTIS, Louise CAMPBELL, David STRACHAN |
| Abstract Mechanisms for learning from incident reporting are generally well established in high reliability organisations. However this is less true within healthcare. In addition, the role of human factors and ergonomics (HFE) in enhancing safety within healthcare is only now being appreciated. This study explored the use of simulation as a method of learning from error and increasing understanding of the role of HFE in enhancing human performance. |
Prevalence of Physical Health Symptoms in Police Officers
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Author Kenisha V. NELSON |
| Abstract This study reports on the prevalence of physical health symptoms in Jamaican police officers (N=134) and examines associations between these and gender, age, rank and years of service. The relationships between number of reported symptoms and sickness and doctor visits were also examined. Participants completed a questionnaire using a cross-sectional design. Over 50% of participants reported backache, frequent headaches, heartburn or indigestion, and sleeping problems. Few significant relationships were found with demographic variables and symptoms. Significant relationships between number of symptoms, sickness absence and doctor visits were observed. Implications of the findings and suggestions for future studies are discussed. |
Usability engineering requirements in the UK (MHRA)
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Author Natalie Shortt |
| Abstract This paper provides an overview of usability engineering requirements in the UK, now that it is not a part of the EU. Notably, Human Factors vendors do not need to be local to any region to perform usability engineering activities, but human factors processes need to adhere to local requirements. |
Human factors approach to phlebotomy service review
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Author Sharon Beza, Lauren Morgan, Andrea Granger, Joe McCloud 4 & Peter Jeffries |
| Abstract In acute hospital care, sampling a patient’s blood is frequently used to help guide diagnosis, or to understand a patient’s response to treatment. This means many patients will have their blood taken multiple times during an inpatient stay. The work of phlebotomists has been studied before, and acknowledgements made to how they adjust their practice to balance patient safety in the context of fluctuating demands and challenging work environments and equipment (Pickup et al., 2017). A human factors approach was used to analyse the in-patient phlebotomy service within a local National Health Service (NHS) Trust. Multiple systems related issues particularly at organisational level were identified. Recommendations were made on how to improve the safety and reliability of the process. |
Development and Validation of a Lighting Assessment Questionnaire for Hospitals
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Author Maryam Karimi, Masoud Shafiee Motlagh, Rostam Golmohammadi, Mohsen Aliabadi & Maryam Farhadian |
| Abstract A questionnaire was designed consisting of 7 main sections and a section entitled "Suggestions for improving brightness". The validity of the questionnaire was determined based on expert comments and the CVI index. Its reliability was assessed by completing the questionnaire by hospital staff. According to the North American Society of Lighting Engineers (IESNA) standard, illumination was evaluated and compared with the questionnaire results. The Cronbach's alpha coefficient and CVI value of the questionnaire were estimated to be 0.901 and 0.97, respectively. There was a significant positive relationship between the mean score of the questionnaire and the illuminances in the workstations (P = 0.001). 72.8% of the workstations had good lighting, and the results of the questionnaire evaluation in these stations showed good and excellent lighting conditions. |
Embedding Resilience Engineering in an Applied Patient Safety Research Programme
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Author Mark Sujan, Mudathir Ibrahim, Lesley Booth, Saydia Razak, Laurie Earl & Peter McCulloch |
| Abstract A 5-year applied research project is described, which uses Resilience Engineering principles to design interventions to improve the management of deteriorating patients following surgery. A rigorous stepped-wedge trial design is used to help construct a more persuasive case for the benefit of Resilience Engineering and Human Factors / Ergonomics in healthcare. |
A human factors approach to understanding information flow in the discharge process
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Author Eva-Maria Carman, Mike Fray and Patrick Waterson |
| Abstract Care transitions are a common feature in healthcare, as patient care usually will require input from a range of healthcare providers. This requires the interaction of various subsystems and a degree of coordination to ensure continuity of care is provided. At these transition points, continuity of care is often put at risk due to a lack of coordination of the discrete elements of care originating from different subsystems. This has resulted in care transitions becoming commonly recognised as an area of risk for patient safety. The aspect of continuity of care that was the focus of this study was that of informational continuity. This study aimed to understand the required information flow for care transitions from acute care to community-based care and develop an intervention toolkit, based on participatory ergonomics. The methods used to map the information flow and identify associated constraints included the analysis of 374 incident reports, 87 patient complaint reports, two focus groups with community staff involved in this process and three observation sessions on the tasks associated with this care transition. The intervention toolkit was developed using a literature review, the two focus groups held with community staff and seven interviews with acute staff involved in the discharge process. Common themes relating to problems associated with information flow that were identified included communication problems with patients, their families, other services involved in the process; difficulties in retrieving the required information, inaccurate information provided; missing or insufficient information transmitted and missing and unclear documentation. The proposed intervention toolkit consisted of four intervention suggestions, namely supporting documentation or education on available services and the process for staff and patients, a discharge checklist to aide acute staff and a decision guide for referrals to district nursing services to ensure appropriate referrals. |
Examining cognitive tasks in the emergency department
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Author Nick Woodier, Paul Davis, Laura Pickup, Kathryn Whitehill & Robert Hutton |
| Abstract Applied Cognitive Task Analysis is an appropriate method to investigate challenging cognitive tasks and the role of expertise in healthcare contexts. Healthcare needs to support the accelerated development of decision-making skills in its novices and also create the optimum conditions in which to make decisions. |
Clinician perspectives around automating the Emergency Department triage process
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Author Katherine L. Plant, Beverley Townsend, & OlTunde Ashaolu |
| Abstract Healthcare has arguably been the sector most impacted by the Covid-19 pandemic, leaving Emergency Department (ED) medical teams overworked and understaffed. An automated system for ED triage has been developed to help alleviate some of these pressures. Eight ED clinicians were interviewed to capture their views of the automated system. Insights were generated around where this system might add value and areas of challenge or concern. These findings will be used to refine the prototype for end-user testing and support the development of training material for clinicians. |
Healthcare Work System Analysis using in-situ Simulation: Case Studies from a Regional Centre
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Author Nick WOODIER, Mark FORES, Clare BARROW, Adrian KWA, Rama NATARANJAN and Bryn BAXENDALE |
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Near, but stopped… defining near miss as controls to support healthcare learning
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Author Nick Woodier, Charlotte Burnett, Bryn Baxendale & Iain Moppett |
| Abstract A near miss in healthcare represents a situation where a negative outcome for a patient was avoided, but it was a near thing. Healthcare has long struggled to embed reporting and learning from near misses, with limited clarity on what a near miss is. This study aimed to learn from industries beyond healthcare to identify the features of a near miss and clarify a definition for healthcare. A mixed methods study was undertaken with healthcare and industry safety experts providing their views on an example case study. The study found that definitions may not be completely clear in industries beyond healthcare, but there is still opportunity to learn. The features of a near miss were found to be orientated around the role of controls in an event sequence, that almost resulted in events reaching and impacting on a patient. The authors advocate for a broad definition for healthcare, with value in identifying where humans are required to intervene to prevent incidents occurring. These situations may offer opportunities to develop more robust controls in healthcare systems to provide barriers to incidents. |
A Vision for the Future of Radiotherapy
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Author Daniel P. JENKINS, Andrew WOLFENDEN, David J. GILMORE, Malcolm BOYD |
| Abstract This paper describes how a suite of research techniques were used to inform the development of a vision for the future of radiotherapy. The aim of the vision was to conceptualise a next-generation radiotherapy system that creates a step-change in system performance. The impact of the vision on patient and HCP experience, safety, and efficiency were all explicitly considered and measured. The vision was used to inform the design of Elekta’s release of Atlantic – a high-field MRI-guided radiation therapy system. |
Ergonomic chair design for ENT, Eye, Neurosurgery and Plastic surgeons
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Author Shahrzad Riaei, Hadi Daneshmandi, Mohsen Razeghi, Bahram Kouhnavard & Zahra Zamanian |
| Abstract Surgeons usually work with sharp tools and sophisticated equipment that create many opportunities for neck, finger, hand, arm or wrist injuries. Despite their limited knowledge of ergonomics, they try to reduce pain during surgery. The most commonly used approach is position change. Today, surgeons use minimally invasive methods. These procedures often impose more physical needs on the surgeon than open surgery. Ergonomic chairs designed for surgeons do not provide the ergonomic position required for microscopic surgery but they can prevent back pain during open surgery. Over the past two decades, new innovations have led to a significant increase in the prevalence of microscopic surgeries, so this study aimed to investigate the characteristics of an ergonomic surgeon chair and its design for use in microscopic surgeries. |
Can we enhance transfusion incident reporters’ awareness of human and organisational factors?
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Author Alison Watt, Gyuchan Thomas Jun & Patrick Waterson |
| Abstract The importance of considering human and organisational factors when reporting transfusion incidents has been highlighted recently. The UK haemovigilance scheme, Serious Hazards of Transfusion (SHOT), has established over the past two decades that most incidents are caused by human errors in the transfusion process. To enhance the incident reporter’s awareness of human and organisational factors, we implemented two interventions and evaluated the effects. First, we created and incorporated a bespoke human factors investigation tool (HFIT) which explicitly asks for the level of contribution of individual staff member(s), the local environment or workspace, organisational or management and government or regulation. Second, we created and incorporated a self-learning package linked to the UK national haemovigilance reporting database, showing both good and poor examples of human and organisational factors reporting with discussions about the merits of these different reports. Data from this tool have been analysed to investigate whether increased learning is possible. The main conclusion after one year’s use of the HFIT, was that incident reporters tended to attribute culpability mostly to individuals (62.6%). It is possible this result is due to lack of system awareness amongst incident reporters. Six-month initial data analysis after the inclusion of the self-learning package shows that if the incident reporter has studied the self-learning package before scoring the level of contribution associated with an incident, there is a slightly lower tendency to attribute most responsibility to individuals. |
Can We Learn about Human and Organisational Factors from Past Transfusion Errors?
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Author Alison WATT, Gyuchan Thomas JUN, Patrick WATERSON |
| Abstract Seven human factors models were evaluated using a small number of historical transfusion error reports to explore learning from human and organisational factors to decide the best model for a larger retrospective study. Insufficient information given in many reports led to subjectivity in categorisation, but the conclusion was that the systems engineering initiative for patient safety 2.0 may be the best single system to use. Analysing the human factors effectively in transfusion incidents could provide some insights into process improvement. |
Component Size Mismatch in Total Hip Arthroplasty: Identifying Risk Factors associated with this Surgical Never Event
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Author Elliott Attilio PATA and Sue HIGNETT |
| Abstract This paper presents an evaluation into the causes of the surgical Never Event ‘Component Size Mismatch’ in total hip arthroplasty. A single-centre prospective service evaluation was conducted at specialist orthopaedic hospital in the UK. Hierarchical Task Analysis and Healthcare Failure Modes and Effects Analysis were used to analyse perioperative procedures and identify potential causes and interventions. Key vulnerabilities in the system included, but were not limited to, poor implant labelling, distractions, communication error, and a difficult working environment. Interventions to reduce this Never Event are proposed and could be tested in simulation environments. |
Limiting Anthropometric Criteria for Medical Staff when Undertaking Aeromedical Operations in Rotary Wing Aircraft
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Author Karl J. Rich, Joy Ho & Cameron Edgar |
| Abstract New South Wales (NSW) Ambulance Aeromedical Operations Division (AOD) is standardising helicopter types with increased reliance on the Leonardo AW139. The AW139 has specified limits for the height and weight of medical crew (doctors and paramedics) when harnessed to the front and rear anchor points within the helicopter, and specified limits for the combined weight of medical crew, patients and equipment during stretcher winching operations. An anthropometric analysis was conducted to provide guidance on the height and weight ranges applicable to crew members based on the limitations of three system components: cabin seated height, hardpoint limit and winch limits (during stretcher winching operations). It was determined that seated height is a key dimension that would limit crew ability to interact with the cabin, this was at 935mm with helmet, clothing and seat depression correction factors included. This corresponds to 91st%ile Australian male seated height and 99th%ile Australian female seated height. Therefore, most of the Australian population should be able to sit in the cabin based on this dimension. In the analysis, hardpoint and winch weight limitations do not exclude a significant portion of the Australian population (e.g., 3% of males with a hardpoint weight limit of 130kg). However, it was found that the higher the weight of the crew member, the lower the weight of the patient that can be safely winched, especially when winching occurs below 0°C. Tables were developed to illustrate the effect of the limitations of system components on crew weight. It is concluded that the interaction of the analysed system component with patient weight would be key in understanding applicable crew height and weight ranges. It is recommended that seated height be formalised as an initial guidance, followed by ensuring crew understand the interrelationship between the safe working load on the hardpoint, weight on the winch and patient weight. This presented a good opportunity for NSW Ambulance AOD to integrate calculations of system component limits into formalised training. The operational context and general health/fitness to fly would also need to be considered for effective aeromedical operations. |
Usability engineering for a complex, medical device: a case study of an MR-Linac
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Author David J Gilmore & Ashleigh Shier |
| Abstract This paper summarises the activities required and complexities encountered while undertaking the usability engineering process for a large, complex, and new-to-the-world medical device – namely Elekta Unity, the first high field Magnetic Resonance (MR)-Linac. The early design-oriented activities have been presented previously, but the usability engineering has predominantly taken place since then. The main challenges lie in the sheer complexity of such a device – combining two potentially harmful technologies into one, in a usage context with many users with different roles to play, and where different components may have their own regulatory documentation. |
Soft Factors for Hard Decisions
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Author David HITCHCOCK and Sue SMALLEY |
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Organizing for safety in general practice medicines management: findings from a field study
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Author Denham PHIPPS, Anthony AVERY, and Darren ASHCROFT |
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The Pressures Diagram: Illustrating Pressures and Trade-offs in Healthcare
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Author Natalie Sanford, Mary Lavelle, Ola Markiewicz, Gabriel Reedy, Anne Marie Rafferty & Janet E. Anderson |
| Abstract Healthcare is challenged by pressures on every level of the system. This short paper introduces the Pressures Diagram as a tool to communicate pressures and the prioritisation of pressures, affording greater insight into the complexity of healthcare work. |
Holistic outcome-driven approach: How do patients and providers prioritise healthcare outcomes?
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Author I. Cecilia Landa-Avila, Gyuchan Thomas Jun, Carolina Escobar-Tello and Rebecca Cain |
| Abstract Healthcare systems are facing pressures to fulfil various needs from different stakeholders at different levels. Different stakeholders tend to prioritise different sets of healthcare outcomes. Consequently, how outcomes are valued or prioritised by different stakeholders needs to be understood in a holistic way to develop and improve new or existent systems. Human factors frameworks and approaches such as Systems Engineering Initiative for Patient Safety (SEIPS) and Cognitive Work Analysis (CWA) recognise the importance of outcomes, but fewer practical approaches for understanding and communicating outcomes as interrelated systems exist. This study applied network analysis as a practical approach to collect, aggregate and visualise interrelations among multiple outcomes. Also, this practical approach provides a mechanism for different stakeholders to communicate and negotiate priorities for holistic outcome-driven healthcare system development. We conducted graphic facilitation mapping interviews with ten patients with chronic conditions and eleven healthcare providers. Participants built outcome interrelationship maps following three steps: 1) Select and explain meaningful and ideal outcomes. 2) Make sense of outcomes by creating influence relationships and groups. 3) Select the most important outcome. Two outcome-based visualisations emerged from the network analysis respectively for patients and healthcare providers. Agreements, disagreements and critical outcomes between patients and providers were identified from those analyses. Wellbeing was equally acknowledged by both groups. However, patients prioritised outcomes such as personal resilience and self-monitoring, while providers prioritised integrated working, (re)admissions and hospitalisations. Overall, this practical approach contributes to a holistic outcomes integration for healthcare systems developing. The mapping process supports interrelated outcomes collection, while the network analysis offers a novel visual communication strategy to identify critical outcomes. This practical approach may complement frameworks such as SEIPS and CWA. A further study could be conducted to explore how multiple stakeholders use this approach for collectively discussing and negotiating their outcome prioritisation. |
Analysing two serious incidents in clinical research from a systems theory perspective
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Author Anthony Vacher, Yannick Bardie, Monica Pollina, Myra Daridan and Brian Edwards, for the Safety Analysis Team |
| Abstract Effectively ensuring the safety of volunteers that participate in clinical trials involving healthcare products (drugs, medical devices) is a subject of debate in clinical research. This is especially so when healthy volunteers choose to enter Phase I (first-in-human) trials where any serious incident is unacceptable and undermines the confidence in the whole healthcare industry. As in other industries, safety management of clinical trials rely mainly on a traditional view that aims to avoid serious incidents by the identification of hazards, the development of safety barriers (technological barriers, procedures, regulation, laws) to prevent and mitigate risks, and the strict compliance of operators with these safety barriers. This traditional view of safety management is recognised as no longer sufficient to maintain safety in a dynamic, complex, and competitive environment where changes and perturbations are permanent, and the pace of technological innovations is high. In that respect, a group of individual pharmacology and clinical professionals have argued for the need to introduce the principles and methods from human factors and systems theory into the process of safety investigations following serious incidents occurring in clinical research. In this perspective, an international, interdisciplinary and multi-stakeholder collaboration was established to explore the feasibility to transpose human factors and systems theory methods to the specific context of investigation of serious incidents that occurred during phase I-trials. The Causal Analysis using System Theory method was applied to two emblematic serious incidents, one in London (United Kingdom) in 2006 and one in Rennes (France) in 2016. These two serious incidents have benefited from extensive investigations by both stakeholders and authorities afterwards to identify their root-causes and propose remedial actions to avoid their recurrence. |
Identifying work system components and constraints of cancer multidisciplinary team meetings
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Author Eva-Maria Carman, Giulia Miles, Sarah Gregory, Gemma Bristow, Eleanor Robinson, James Catton, Alastair Ross and Bryn Baxendale |
| Abstract Multidisciplinary teams have been introduced into cancer care to improve quality of care and are now considered the gold standard for the management of cancer patients in the UK. Meetings of these teams provide an opportunity for experts to discuss the best possible treatment options for the patient. Trends show that referral numbers to these meetings are increasing, placing strain on the capacity of meetings to function optimally. This in turn has cognitive and workload implications for staff involved. Promoting MDT Excellence is a project that aims to examine the variation in practice of these meetings across one NHS Trust and to understand the challenges they are currently facing. In the first phase of this project, a systems analysis of cancer multidisciplinary teams was conducted for the purpose of identifying system constraints and resource issues. A total of twelve meetings were observed, and 42 staff from four specialties were interviewed. Using the SEIPS 2.0 model, key work system components and constraints for multidisciplinary team meetings were identified for the people involved, the tasks, tools and technology, organisation of work, internal environment and external environment. Furthermore, aspects that promoted efficient ways of working and positive outcomes were captured. Examples identified included adopting a more structured agenda, real time digital notetaking and different work organisation techniques, such as distribution of responsibilities and the scheduling of patient groups to be discussed during the meeting. These results provide the basis for a multifaceted approach for system improvement for this work process. |
Putting Ostomates at the Heart of Pouch Design
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Author Anna McLister, Chloe Roberts & A C B Medeiros |
| Abstract Ostomy pouches are used daily by over 13,000 people in the UK each year, to collect effluent from their stomas. Although this Class I medical device has undergone a design revolution since the 1940s, ostomates’ needs are still not being fully realised. Building upon knowledge and insights gained from interviewing and surveying ostomates, this paper will explore how applying key Human Factors considerations could help inform the future design of ostomy pouches and ultimately, improve the quality of life of ostomates. |
Understanding Complex Work Using the Resilience Mechanisms Framework: An Ethnographic Study
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Author Natalie Sanford, Dr Mary Lavelle, Dr Ola Markiewicz, Dr Gabriel Reedy, Professor Anne Marie Rafferty, & Professor Janet E. Anderson |
| Abstract Resilient Healthcare is an emerging theoretical field that has developed with influence from engineering, safety science, psychology, ergonomics, human factors, and aeronautics. Resilient Healthcare research has centred on understanding and improving the quality and safety of healthcare delivery. Theory is increasingly well-developed, but so far has only been applied in limited ways with select settings and activities. In order to improve the quality and safety of healthcare, it is essential to first understand the sources of complexity in clinical work. This ethnographic study of five hospital teams in a large, teaching hospital in central London aims to contribute to this growing evidence base by presenting data on specific challenges faced by healthcare workers and the adaptations they use to overcome them in everyday clinical work. This paper will present a new framework for recognising misalignments between demand and capacity and corresponding mechanisms for adaptation, which can be used to understand work-as-done in complex settings and to manage risk. |
Using the decision ladder to reach a better design
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Author Daniel P. JENKINS, Malcolm BOYD, Chris LANGLEY |
| Abstract As with all safely critical interfaces, it is imperative that medical devices communicate the right information, to the right people, at the right time, in the right place, and in an optimal format. This paper describes an approach for eliciting information requirements based on Rasmussen’s decision ladder. A hypothetical example of radiography equipment is used to illustrate the process; however, the approach is also considered to be applicable to a wide range of domains. The approach is based on a semi-structured interview and creates an explicit link between the data collection activity and the final design interface. |
Resilient Health Care in the use of intravenous insulin infusions
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Author Mais Iflaifel, Rosemary Lim, Clare Crowley, Francesca Greco, Kath Ryan, Rick Iedema |
| Abstract Variable rate intravenous insulin infusions (VRIIIs) are used to treat elevated blood glucose in severely ill hospitalised patients and those with diabetes missing more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Conventional approaches to increasing safety have focused on linear thinking by first identifying errors, then finding solutions to prevent future recurrence. Resilient Health Care proposes improving patient safety by understanding the variability in everyday clinical work in order to realign ‘Work as Imagined’ (WAI): what people say, or think they do, with ‘Work as Done’ (WAD): what people actually do in practice. This study aimed to explore resilience in the use of VRIII in adult inpatients by comparing WAI with WAD. WAI was explored by analysing VRIIIs guidelines and focus groups with different stakeholders involved in the process of using VRIIIs. WAD was explored by first videoing healthcare practitioners while using VRIII, selecting video clips and discussing them with participants in reflexive meetings, then transcribing and analysing the reflexive meeting discussions. Two hierarchical task analyses (HTA) were developed to systematically represent WAI and WAD. Although most of the tasks in WAD HTA generally aligned with WAI HTA, some misalignments were observed. Misalignment was identified in different type of tasks including emergent, complex tasks as well as simple and complicated tasks. The majority of the observable adaptations used to respond to emergent tasks were forced adaptations or temporary workarounds where ideal solutions were not possible at that time. |
Understanding the relationship between resilience and care quality in home care support
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Author Jan Healey, Sue Hignett & Diane Gyi |
| Abstract A resilient healthcare theoretical framework was applied to identify the performance obstacles and corresponding adaptations home care workers make in the delivery of home care support to provide an understanding of the relationship between home care resilience and quality of care. |
Human factors: emergency department suspected heart attack process
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Author Frances Ives & Deborah Jackson |
| Abstract Early recognition of a heart attack is essential as delayed treatment can result in death. A Human Factors (HF) review of the process for treating suspected heart attack patients in a busy inner-city Emergency Department (ED) was completed to help decrease risk, improve patient safety, care and patient and staff experience. To provide timely treatment for a heart attack, a diagnostic electrocardiogram (ECG) must be performed within 15 minutes of arrival at ED. However, concerns had been raised by staff relating to patient experience and delayed ECG, due to the number of process steps the patient had to complete from arrival at ED reception to the ECG being taken. Observations of the process were carried out along with multidisciplinary staff focus groups to understand the patient journey. A Hierarchical Task Analysis (HTA) and Failure Modes Effects Analysis (FMEA) were also completed to identify process failures and impact. The FMEA and observations identified that the patient journey was complex due to: the distance they were required to walk; having to enter the department through the ambulance entrance; and the requirement to speak to a specific member of staff in the department to obtain further directions. The process was changed to: reduce the distance the patient had to walk; decrease the likelihood for them to get lost; improve patient visibility for staff; and to facilitate more timely ECGs. As result of the Human Factors review, ED staff felt empowered to make immediate, no-cost and sustainable improvements. |
Significant event analysis: a systems approach to exploring personal impact and improving the analytical process in primary care
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Author Paul BOWIE, Elaine MCNAUGHTON, Deirdre HOLLY, John MCKAY and David BRUCE |
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Design Blindspots: User testing clinical IT systems
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Author Lauren J Morgan & Paula Pryce |
| Abstract In early 2021, the MHRA launched its guidance on applying human factors and usability engineering to medical devices including drug-device combination products in Great Britain (MHRA, 2021). In its guidance it states: A usability engineering process can, and should, be applied by device manufacturers in the identification, assessment and mitigation of potential patient and user safety risks; also in the analysis of incidents that have occurred, in order to identify learning and put into place corrective actions to improve device design However, experience in hospital healthcare is that many devices and IT systems are often poorly designed and continue to contribute to patient safety risks. A seminar Harvard Business Review paper stated: “to fix physician burnout, we must first fix the electronic patient record”. In everyday work in our hospitals we see examples where poor device and IT design is making clinicians lives harder, and decreasing patient safety as a consequence. We have a workforce cataclysm, of which the state of hospital devices and IT is possibly contributing to rather than helping to fix. We explore a simplified multi-method approach to user testing to identify patient safety and usability risks. We present evaluations of 3 clinical IT systems, showing how user testing conducted correctly easily identifies these safety risks. The MHRA guidance as currently stands is not being used fully by suppliers, we need to consider how to strengthen its impact. |
A discussion relating individual performance evaluation and mental health: Research conducted in public services in Brazil
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Author Laerte Idal Sznelwar, Ruri Giannini, Daniele Pimentel Maciel and Selma Lancman |
| Abstract The results presented here are related to the research ‘Construction of intersectoriality in the health and work field: Perspective of professionals inserted in the service network of the city of São Paulo’. The main objective of this research is to understand, through the approach of psychodynamics of work (PDW), the work processes of various actors that are in the frontline of the implementation of different policies (Brasil, 2011). One of the main issues that emerged throughout the research concerns the relationship between work and performance appraisal systems, more specifically in the Labour Court. From the evidence already obtained, we can consider that the performance evaluation systems disregard the real work – they are based on production goals defined from strategic objectives adopted without considering what judges actually face, as well as the servitors who work in support teams. There is still a great distortion regarding alignment with the values of the profession. Often, when seeking to achieve goals, other issues are relegated, such as treating cases with stronger degrees of complication, as if they were similar to others considered as routine. Another distortion is that there is not really an engagement in improving the quality of work – there are almost no organisational devices for discussion and feedback. The main purpose is to meet deadlines and goals regarding production volumes rather than to analyse and increase the usefulness of the performance of these public actors. As these evaluation processes, different reward modalities such as promotions and getting more resources, are also involved, there is an even greater distortion, even if this puts different actors in a difficult situation regarding ethical issues. The emergence of pathogenic suffering is one of the mental health consequences of judges and servitors. |
A model of Human Factors for frontline healthcare staff: Translation to clinical practice
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Author Nick WOODIER, Jonathan FOX and Bryn BAXENDALE |
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The NHS health check for developing HFE competencies
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Author Helen Vosper, Paul Bowie & Sue Hignett |
| Abstract Patient safety is an emergent property of complex sociotechnical healthcare systems. Human Factors and Ergonomics (HFE), with its design-based systems focus, offers frameworks for developing resilient systems, although use in healthcare has been limited to date. Most healthcare educational curricula articulate requirements for students to develop patient safety competencies, but there is scant direction as to how this might be achieved. The authors have produced guidance on embedding HFE in healthcare curricula, but recognise that examples of effective HFE teaching would further support educational practice. This case study outlines a related set of activities based around the NHS Health Check, a population-wide screening programme designed to identify and manage cardiovascular risk. The Health Check represents a cardiovascular risk management system and is amenable to analysis using HFE frameworks. The educational activities described support students in developing a deep awareness of HFE theory, and early development of HFE competencies. The Health Check is a highly relevant professional activity for pharmacy students but would also be relevant to medical and nursing students, as well as healthcare management staff. This case study will form the focus of a discussion that will provide delegates with an opportunity to share experiences of different approaches to HFE education. |
Predicting Upper Limb Discomfort for Plastic Surgeons: combining anthropometric models with Rapid Upper Limb Assessment (RULA)
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Author Zhelin LI, Chris BABER, Christopher MACDONALD and Yvette GODWIN |
| Abstract Plastic surgeons report neck, shoulder and back pain after wearing loupes during operations. This research aimed to discover the inter-relation between factors leading to upper-limb discomfort e.g. viewing angle, stature, or height at which the operation is performed. Ten postures are simulated using digital human models. We then apply multi-objective optimization to characterize the posture of the surgeon in relation to musculoskeletal risk (defined using RULA). It is possible to predict RULA scores for the range of postures. This could be used to quantify risk assessment, particularly in the selection and fitting of loupes and the specification of working height for surgery. Adjusting the operating height could decrease neck flexion angle and reduce musculoskeletal risk. |
Touchscreen usage with upper limb prostheses: initial explorations
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Author Phil Day, Elina Jokisuu, Maggie McKendry, Scott Edward, & Rami Abboud |
| Abstract This paper describes a formative investigation into the use of projected capacitive touchscreens with upper limb prostheses. A difference in performance was found between two types of touchscreen, and also between different varieties of prosthesis; although the methodology means that further study is required as the prostheses were held in a simulated contact rather than actually worn in a realistic manner. Even with these caveats, this early work demonstrates the potential problem that exists in using touchscreens with a prosthetic device, and explores some possible solution areas. |
Human Factors Integration Strategy: Embedding Human Factors in Practice within Healthcare
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Author Eva-Maria Carman, Giulia Miles, Bryn Baxendale, Emma Smith & Owen Bennett |
| Abstract Despite identifying the need for enhancing the use of Human Factors and Ergonomics in healthcare about 20 years ago, progress to date has been slow. A cohesive strategy is required that aligns these methods and expertise with established improvement, transformation and organisational development programmes and which is synergistic with existing work that seeks to address local system and organisational priorities. This paper describes progress to date and proposed future steps for the integration of Human Factors and Ergonomics in one large NHS Hospital Trust. |
Guidewire Retention after Central Venous Catheterisation: Prevention and Mitigation using Bow-Tie Analysis
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Author James WARD, Maria Mikela CHATZIMICHAILIDOU, Tim HORBERRY, Yi-Chun TENG and John CLARKSON |
| Abstract Never events are typically rare but serious incidents in healthcare. They are perceived to be preventable, and include the retention of a surgical instrument in a patient's body. One such instrument is a "guidewire", which is used to help introduce a catheter tube into the venous system of a patient. Following a number of guidewire retentions, these authors investigated contributing factors and examined mechanisms to reduce the risk of further occurrences. This paper presents the results in the form of a bow-tie analysis, which was found to provide an effective way to graphically display and examine the issue. |
Blood sampling in acute hospital care settings: A Human Factors Review
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Author Laura PICKUP, Sarah ATKINSON, Sam RAWLINSON, Paul BOWIE, Sandra GRAY, Douglas WATSON, Diane SYDNEY, Lorna SINCLAIR, Catherine INNES, Caroline IZATT, Jane OLDHAM, Katherine FORRESTER & Erik HOLLNAGEL |
| Abstract Blood sampling is a routine activity within healthcare relied upon for safe patient care. The aim of this pilot study was to apply a Human Factors/Ergonomics systems approach to understand why variability in performance of blood sampling continues to be reported despite various initiatives, procedures and national guidelines (Milkins et al 2012). A multi method approach was adopted and included the application of the Functional Resonance Analysis Method (FRAM) (Hollnagel 2012). The context of an emergency department was analysed and modelled to consider how the concept |
The Impact of Government Health and Safety on Healthcare and Ergonomics in the United States
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Author Marc CHRISTIAN, Jeffrey E. FERNANDEZ, Anand SUBRAMANIAN, and Brandy Farris WARE |
| Abstract The purpose of this paper is to examine a major cost associated with the healthcare industry: health and safety. The labor regulatory agency (OSHA) in the USA have recently targeted healthcare facilities with high fines for a number of high-cost injury categories. The reasons for and implications of this enforcement policy are discussed, and a case study regarding ergonomic interventions in healthcare is presented to emphasize the importance of proactive risk reduction measures. Additional benefits of the intervention included increased productivity, throughput, and employee satisfaction. |
Facilitators and barriers to a safe opioid prescribing process in general practice
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Author Gill Gookey & Mike Fray |
| Abstract Opioids e.g., morphine are high-risk medications that are frequently prescribed using a complex process in general practice. The current opioid prescribing process within six general practices was mapped using template analysis which highlighted high levels of variation. The Systems Engineering Initiative for Patient Safety v2.0 framework was used to identify overall aims for a safe opioid prescribing process and associated facilitators and barriers. |
Guidance on customising Bowtie Analysis for use in healthcare
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Author Ronald W. McLeod and Paul Bowie |
| Abstract Based on the CIEHF white paper ‘Human factors in barrier management’, NHS Education for Scotland (NES) has been exploring the potential application of Bowtie Analysis (BTA) in healthcare. Both an initial workshop-based study in a primary care context, as well as feedback from training and a series of case studies conducted across primary and secondary care and supporting health functions, suggested BTA has significant potential as an approach to identifying and managing risk in healthcare. It seems realistic to expect that existing healthcare professionals should be able to conduct BTAs to a reasonable quality standard making use of an NES Guide guidance document, together with a relatively small amount of training and support. |
Technical and collaborative work in the management of acute kidney injury
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Author Denham PHIPPS, Rebecca MORRIS, Thomas BLAKEMAN and Darren ASHCROFT |
| Abstract Patient care may become complicated by acute kidney injury (AKI), a syndrome that affects a patient’s renal functioning. Our study aimed to explore the work involved in dealing with clinical situations where AKI may be present in primary or secondary care. From interviews with 54 doctors and pharmacists in England, we describe their work under three themes: the clinical context; the organisational context; and meeting challenges arising from these contexts. Our findings reflect the role of cognitive work, in particular decision making and collaboration, in facilitating clinical tasks. These should be the focus of any interventions to improve AKI management. |
Addressing staffing crises in transfusion without compromising safety
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Author Simon P Carter-Graham, Jennifer Davies, Emma Milser, Debbi Poles & Shruthi Narayan |
| Abstract A presentation of data submitted to Serious Hazards of Transfusion (SHOT), the UK's Haemovigilance scheme. Data subject is training and competency of healthcare professionals in temporary roles, such as locum or agency. |
