Human Factors Analysis of Latent Safety Threats in a Pediatric Critical Care Unit.

OBJECTIVES: To identify unique latent safety threats spanning routine pediatric critical care activities and categorize them according to their underlying work system factors (i.e., "environment, organization, person, task, tools/technology") and associated clinician behavior (i.e., "legal": expected compliance with or "illegal-normal": deviation from and "illegal-illegal": disregard for standard policies and protocols). DESIGN: A prospective observational study with contextual inquiry of clinical activities over a 5-month period. SETTING: Two PICUs (i.e., medical-surgical ICU and cardiac ICU) in an urban free-standing quaternary children's hospital. SUBJECTS: Attending physicians and trainees, nurse practitioners, registered nurses, respiratory therapists, dieticians, pharmacists, and patient services assistants were observed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Conducted 188 hours of observations to prospectively identify unique latent safety threats. Qualitative observational notes were analyzed by human factors experts using a modified framework analysis methodology to summarize latent safety threats and categorize them based on associated clinical activity, predominant work system factor, and clinician behavior. Two hundred twenty-six unique latent safety threats were observed. The latent safety threats were categorized into 13 clinical activities and attributed to work system factors as follows: "organization" (n = 83; 37%), "task" (n = 52; 23%), "tools/technology" (n = 40; 18%), "person" (n = 32; 14%), and "environment" (n = 19; 8%). Twenty-three percent of latent safety threats were identified when staff complied with policies and protocols (i.e., "legal" behavior) and 77% when staff deviated from policies and protocols (i.e., "illegal-normal" behavior). There was no "illegal-illegal" behavior observed. CONCLUSIONS: Latent safety threats span various pediatric critical care activities and are attributable to many underlying work system factors. Latent safety threats are present both when staff comply with and deviate from policies and protocols, suggesting that simply reinforcing compliance with existing policies and protocols, the common default intervention imposed by healthcare organizations, will be insufficient to mitigate safety threats. Rather, interventions must be designed to address the underlying work system threats. This human factors informed framework analysis of observational data is a useful approach to identifying and understanding latent safety threats and can be used in other clinical work systems.

System Factors Affecting Intraoperative Risk and Resilience: Applying a Novel Integrated Approach to Study Surgical Performance and Patient Safety.

OBJECTIVE: To identify and categorize system factors in complex laparoscopic surgery that have the potential to either threaten patient safety or support system resilience. BACKGROUND: The operating room is a uniquely complex sociotechnical work system wherein surgical successes prevail despite pervasive safety threats. Holistically characterizing intraoperative factors that thus support system resilience in addition to those that threaten patient safety using contextual methodologies is critical for optimizing surgical safety overall. METHOD: In this prospective descriptive interdisciplinary study, 19 audio/video recordings of complex laparoscopic general surgical procedures were directly observed and transcribed. Using a qualitative systems-based approach, intraoperative human factors with the potential to impact patient safety, either as a safety threat or as a support for resilience, were identified. Adverse events were further assessed for shared threats and supports. Data collection was guided by the Systems Engineering Initiative for Patient Safety 2.0 work system model. RESULTS: A total of 1083 relevant observations were made over 39.8 hours of operative time, enabling the identification of 79 distinct safety threats and 67 resilience supports within the surgical system. Safety threats associated with the physical environment, tasks, organization, and equipment were prevalent and observed in equal measure, whereas supports for resilience were predominantly attributed to clinician behaviors, including proactive team management and skills coaching. Two subclinical adverse events were identified; shared safety threats included suboptimal technology design, whereas shared resilience supports included calm clinician behavior and redundant intraoperative resourcing. CONCLUSIONS: Safety threats and resilience supports were found to be systematic in the surgical setting. Identified safety threats should be prioritized for remediation, and clinician behaviors that contribute to fostering resilience should be valued and protected.

Association of Data Integration Technologies With Intensive Care Clinician Performance: A Systematic Review and Meta-analysis.

Importance: Sources of data in the intensive care setting are increasing exponentially, but the benefits of displaying multiparametric, high-frequency data are unknown. Decision making may not benefit from this technology if clinicians remain cognitively overburdened by poorly designed data integration and visualization technologies (DIVTs). Objective: To systematically review and summarize the published evidence on the association of user-centered DIVTs with intensive care clinician performance. Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and Web of Science were searched in May 2014 and January 2018. Study Selection: Studies had 3 requirements: (1) the study tested a viable DIVT, (2) participants involved were intensive care clinicians, and (3) the study reported quantitative results associated with decision making in an intensive care setting. Data Extraction and Synthesis: Of 252 records screened, 20 studies, published from 2004 to 2016, were included. The human factors framework to assess health technologies was applied to measure study completeness, and the Quality Assessment Instrument was used to assess the quality of the studies. PRISMA guidelines were adapted to conduct the systematic review and meta-analysis. Main Outcomes and Measures: Study completeness and quality; clinician performance; physical, mental, and temporal demand; effort; frustration; time to decision; and decision accuracy. Results: Of the 20 included studies, 16 were experimental studies with 410 intensive care clinician participants and 4 were survey-based studies with 1511 respondents. Scores for study completeness ranged from 27 to 43, with a maximum score of 47, and scores for study quality ranged from 46 to 79, with a maximum score of 90. Of 20 studies, DIVTs were evaluated in clinical settings in 2 studies (10%); time to decision was measured in 14 studies (70%); and decision accuracy was measured in 11 studies (55%). Measures of cognitive workload pooled in the meta-analysis suggested that any DIVT was an improvement over paper-based data in terms of self-reported performance, mental and temporal demand, and effort. With a maximum score of 22, median (IQR) mental demand scores for electronic display were 10 (7-13), tabular display scores were 8 (6.0-11.5), and novel visualization scores were 8 (6-12), compared with 17 (14-19) for paper. The median (IQR) temporal demand scores were also lower for all electronic visualizations compared with paper, with scores of 8 (6-11) for electronic display, 7 (6-11) for tabular and bar displays, 7 (5-11) for novel visualizations, and 16 (14.3-19.0) for paper. The median (IQR) performance scores improved for all electronic visualizations compared with paper (lower score indicates better self-reported performance), with scores of 6 (3-11) for electronic displays, 6 (4-11) for tabular and bar displays, 6 (4-11) for novel visualizations, and 14 (11-16) for paper. Frustration and physical demand domains of cognitive workload did not change, and differences between electronic displays were not significant. Conclusions and Relevance: This review suggests that DIVTs are associated with increased integration and consistency of data. Much work remains to identify which visualizations effectively reduce cognitive workload to enhance decision making based on intensive care data. Standardizing human factors testing by developing a repository of open access benchmarked test protocols, using a set of outcome measures, scenarios, and data sets, may accelerate the design and selection of the most appropriate DIVT.

Convergent parallel mixed-methods study to understand information exchange in paediatric critical care and inform the development of safety-enhancing interventions: a protocol study.

INTRODUCTION: The effective exchange of clinical information is essential to high-quality patient care, especially in the critical care unit (CCU) where communication failures can have profoundly negative impacts on critically ill patients with limited physiological capacity to tolerate errors. A comprehensive systematic characterisation of information exchange within a CCU is needed to inform the development and implementation of effective, contextually appropriate interventions. The objective of this study is to characterise when, where and how healthcare providers exchange clinical information in the Department of Critical Care Medicine at The Hospital for Sick Children and explore the factors that currently facilitate or counter established best rounding practices therein. METHODS AND ANALYSIS: A convergent parallel mixed-methods study design will be used to collect, analyse and interpret quantitative and qualitative data. Naturalistic observations of rounds and relevant peripheral information exchange activities will be conducted to collect time-stamped event data on workflow and communication patterns (time-motion data) and field notes. To complement observational data, the subjective perspectives of healthcare providers and patient families will be gathered through surveys and interviews. Departmental metrics will be collected to further contextualise the environment. Time-motion data will be analysed quantitatively; patterns in field note, survey and interview results will be examined based on themes identified deductively from literature and/or inductively based on the data collected (thematic analysis). The proactive triangulation of these systemic, procedural and contextual data will inform the design and implementation of efficacious interventions in future work. ETHICS AND DISSEMINATION: Institutional research ethics approval has been acquired (REB #1000059173). Results will be published in peer-reviewed journals and presented at relevant conferences. Findings will be presented to stakeholders including interdisciplinary staff, departmental management and leadership and families to highlight the strengths and weaknesses of the exchange of clinical information in its current state and develop user-centred recommendations for improvement.