Repentance as Rebuke: Betrayal and Moral Injury in Safety Engineering.

Following other contributions about the MAX accidents to this journal, this paper explores the role of betrayal and moral injury in safety engineering related to the U.S. federal regulator's role in approving the Boeing 737MAX-a plane involved in two crashes that together killed 346 people. It discusses the tension between humility and hubris when engineers are faced with complex systems that create ambiguity, uncertain judgements, and equivocal test results from unstructured situations. It considers the relationship between moral injury, principled outrage and rebuke when the technology ends up involved in disasters. It examines the corporate backdrop against which calls for enhanced employee voice are typically made, and argues that when engineers need to rely on various protections and moral inducements to 'speak up,' then the ethical essence of engineering-skepticism, testing, checking, and questioning-has already failed.

Rethinking preparedness planning in disaster emergency care: lessons from a beyond-surge-capacity event.

BACKGROUND: Large-scale burn disasters can produce casualties that threaten medical care systems. This study proposes a new approach for developing hospital readiness and preparedness plan for these challenging beyond-surge-capacity events. METHODS: The Formosa Fun Coast Dust Explosion (FFCDE) was studied. Data collection consisted of in-depth interviews with clinicians from four initial receiving hospitals and their relevant hospital records. A detailed timeline of patient flow and emergency department (ED) workload changes of individual hospitals were examined to build the EDs' overload patterns. Data analysis of the multiple hospitals' responses involved chronological process-tracing analysis, synthesis, and comparison analysis in developing an integrated adaptations framework. RESULTS: A four-level ED overload pattern was constructed. It provided a synthesis of specifics on patient load changes and the process by which hospitals' surge capacity was overwhelmed over time. Correspondingly, an integrated 19 adaptations framework presenting holistic interrelations between adaptations was developed. Hospitals can utilize the overload patterns and overload metrics to design new scenarios with diverse demands for surge capacity. The framework can serve as an auxiliary tool for directive planning and cross-check to address the insufficiencies of preparedness plans. CONCLUSIONS: The study examined a wide-range spectrum of emergency care responses to the FFCDE. It indicated that solely depending on policies or guidelines for preparedness plans did not contribute real readiness to MCIs. Hospitals can use the study's findings and proposal to rethink preparedness planning for the future beyond surge capacity events.

Uncovering the Value of a Historical Paper-Based Collaborative Artifact: The Nursing Unit's Kardex System.

We identify useful functions and usability characteristics of a historical cognitive artifact used by nurses working in a hospital unit, the Kardex. By identifying aspects of a widely used artifact, we uncover opportunities to improve the usefulness of current systems for hospital nurses. We conducted semi-structured interviews with registered nurses about their prior experience with the Kardex. Questions included what elements of the Kardex are missing from their current electronic support. Memos were generated iteratively from interview transcript data and grouped into themes. Eighteen nurses from multiple clinical areas participated and had a median of 25-29 years of nursing experience. The themes were: (1) a status at a glance summary for each patient, (2) a prospective memory aid, (3) efficiency and ease of use, (4) updating information required to maintain value, (5) activity management, (6) verbal handover during shift-to-shift report, (7) narrative charting and personalized care, and (8) non-clinical care communication. Implications for digital support are to provide immediate, portable access to a standardized patient summary, support for nurses to manage their planned activities during a series of shifts, provide unstructured text fields for narrative charting, and to support adding informal notes for personalized care.

Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion.

OBJECTIVE: The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE). METHODS: Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical records of FFCDE patients and admission logs from the emergency department (ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis focused on how the ED and other units adapted to coping with the difficulties created by the patient surge. RESULTS: The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital reconfigured human and physical resources differently from conventional drills. Graphical timelines illustrate anticipatory or reactive adaptations. The hospital's ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands. CONCLUSION: Adapting to beyond-surge capacity incident is essential to effective disaster response. Building organizational support for effective adaptation is critical for disaster planning.

Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion.

PURPOSE: To provide an insight into the challenges faced by the closest hospital to the Formosa Fun Coast Dust Explosion (FFCDE) disaster scene, and to examine how the hospital staff adapted to cope with the mass burn casualty (MBC) in their overcrowded emergency department (ED) after the disaster. MATERIAL AND METHODS: The critical incident technique was used for the investigation. Data was gathered through in-depth individual interviews with 15 key participants in this event. The interview data was combined with the medical records of the FFCDE patients and admission logs to build a detailed timeline of ED workload. Process tracing analysis was used to evaluate how the ED and other units adapted to deal with actual and potential bottlenecks created by the patient surge. RESULTS: Fifty-eight burn patients were treated and registered in approximately six hours while the ED managed 43 non-FFCDE patients. Forty-four patients with average total body surface area burn 51.3% were admitted. Twenty burn patients were intubated. The overwhelming demand created shortages primarily of clinicians, ED space, stretchers, ICU beds, and critical medical materials for burn care. Adaptive activities for the initial resuscitation are identified and synthesized into three typical adaptation patterns. These adaptations were never previously adopted in ED normal practices for daily surge nor in periodical exercises. The analysis revealed adaptation stemmed from the dynamic re-planning and coordination across roles and units and the anticipation of bottlenecks ahead. CONCLUSION: In the hospital closest to the FFCDE disaster scene, it caused an overwhelming demand in an already crowded, beyond-nominal-capacity ED. This study describes how the hospital mobilized and reconfigured response capacity to cope with overload, uncertainty, and time pressure. These findings support improving disaster planning and preparedness for all healthcare entities through organizational support for adaptation and routine practice coping with unexpected scenarios.

Value and Usage of a Workaround Artifact: A Cognitive Work Analysis of "Brains" Use by Hospital Nurses.

We identify the value and usage of a cognitive artifact used by hospital nurses. By analyzing the value and usage of workaround artifacts, unmet needs using intended systems can be uncovered. A descriptive study employed direct observations of registered nurses at two hospitals using a paper workaround ("brains") and the Electronic Health Record. Field notes and photographs were taken; the format, size, layout, permanence, and content of the artifact were analyzed. Thirty-nine observations, spanning 156 hr, were conducted with 20 nurses across four clinical units. A total of 322 photographs of paper-based artifacts for 161 patients were collected. All participants used and updated "brains" during report, and throughout the shift, most were self-generated. These artifacts contained patient identifiers in a header with room number, last name, age, code status, and physician; clinical data were recorded in the body with historical chronic issues, detailed assessment information, and planned activities for the shift. Updates continuously made during the shift highlighted important information, updated values, and tracked the completion of activities. The primary functional uses of "brains" are to support nurses' needs for clinical immediacy through personally generated snapshot overviews for clinical summaries and updates to the status of planned activities.

Performance of experienced versus less experienced paramedics in managing challenging scenarios: a cognitive task analysis study.

STUDY OBJECTIVE: Out-of-hospital care is becoming more complex, thus placing greater reliance on the cognitive abilities of paramedics to manage difficult situations. In adapting to the challenges in their work, paramedics develop expertise. We study the cognitive strategies used by expert paramedics to contribute to understanding how paramedics and the EMS system can adapt to new challenges. METHODS: We conducted a "staged-world" cognitive task analysis to explore paramedics' handling of cognitive challenges related to sense-making and to resource and task management. A mixed-fidelity simulation was used to present paramedics with 2 challenging scenarios: a pulmonary embolism initially presenting as a myocardial infarction and a 2-person shooting with limited resources available. RESULTS: Participants were 10 paramedics, 6 more experienced and 4 less experienced. Analysis involved comparing the performance of the 2 groups to identify strategies associated with expertise. The more experienced paramedics made more assessments, explored a wider variety of presumptive diagnoses, and identified the pulmonary embolism earlier. They switched attention between the 2 shooting victims more, used their emergency medical technician-basic level partners more, and provided more advanced level care for both patients. Their patients arrived at the emergency department more prepared for specialized emergency care. CONCLUSION: Our findings correspond to general cognitive attributes of expertise: greater cue gathering and inferential reasoning, and more functional and strategic thinking. These results suggest potential areas and methods to facilitate development of expertise, as well as ways to better support use of expertise. Future studies should expand on these findings through larger sample sizes and more complex scenarios.

Handoff strategies in settings with high consequences for failure: lessons for health care operations.

OBJECTIVE: To describe strategies employed during handoffs in four settings with high consequences for failure. ANALYSIS: of observational data for evidence of use of 21 handoff strategies. SETTING: NASA Johnson Space Center in Texas, nuclear power generation plants in Canada, a railroad dispatch center in the United States, and an ambulance dispatch center in Toronto. MAIN MEASURE: Evidence of 21 handoff strategies from observations and interviews. RESULTS: Nineteen of 21 strategies were used in at least one domain, on at least an 'as needed' basis. CONCLUSIONS: An understanding of how handoffs are conducted in settings with high consequences for failure can jumpstart endeavors to modify handoffs to improve patient safety.