Checking all the boxes: a checklist for when and how to use checklists effectively.

Checklists are a type of cognitive aid used to guide task performance; they have been adopted as an important safety intervention throughout many high-risk industries. They have become an ubiquitous tool in many medical settings due to being easily accessible and perceived as easy to design and implement. However, there is a lack of understanding for when to use checklists and how to design them, leading to substandard use and suboptimal effectiveness of this intervention in medical settings. The design of a checklist must consider many factors including what types of errors it is intended to address, the experience and technical competencies of the targeted users, and the specific tools or equipment that will be used. Although several taxonomies have been proposed for classifying checklist types, there is, however, little guidance on selecting the most appropriate checklist type, nor how differences in user expertise can influence the design of the checklist. Therefore, we developed an algorithm to provide guidance on checklist use and design. The algorithm, intended to support conception and content/design decisions, was created based on the synthesis of the literature on checklists and our experience developing and observing the use of checklists in clinical environments. We then refined the algorithm iteratively based on subject matter experts' feedback provided at each iteration. The final algorithm included two parts: the first part provided guidance on the system safety issues for which a checklist is best suited, and the second part provided guidance on which type of checklist should be developed with considerations of the end users' expertise.

Leveraging the Science of Teamwork to Sustain Handoff Improvements in Cardiovascular Surgery.

BACKGROUND: Improving the reliability of handoffs and care transitions is an important goal for many health care organizations. Increasing evidence shows that human-centered design and improved teamwork can lead to sustainable care transition improvements and better patient outcomes. This study was conducted within a cardiovascular service line at an academic medical center that performs more than 600 surgical procedures annually. A handoff process previously implemented at the center was poorly adopted. This work aimed to improve cardiovascular handoffs by applying human factors and the science of teamwork. METHODS: The study's quality improvement method used Plan-Do-Study-Act cycles and participatory design and ergonomics to develop, implement, and assess a new handoff process and bundle. Trained observers analyzed video-recorded and live handoffs to assess teamwork, leadership, communication, coordination, cooperation, and sustainability of unit-defined handoff best practices. The intervention included a teamwork-focused redesign process and handoff bundle with supporting cognitive aids and assessment metrics. RESULTS: The study assessed 153 handoffs in multiple phases over 3 years (2016-2019). Quantitative and qualitative assessments of clinician (teamwork) and implementation outcomes were performed. Compared with the baseline, the observed handoffs demonstrated improved team leadership (p < 0.0001), communication (p < 0.0001), coordination (p = 0.0018), and cooperation (p = 0.007) following the deployment of the handoff bundle. Sustained improvements in fidelity to unit-defined handoff best practices continued 2.3 years post-deployment of the handoff bundle. CONCLUSION: Participatory design and ergonomics, combined with implementation and safety science principles, can provide an evidence-based approach for sustaining complex sociotechnical change and making handoffs more reliable.

Handoffs and Teamwork: A Framework for Care Transition Communication.

BACKGROUND: Handoffs occur frequently in the medical domain and are associated with up to 80% of medical errors. Although research has progressed, handoffs largely remain inadequate. The absence of an appropriate conceptual model for handoffs hinders the purposeful design and evaluation of handoff procedures. This article presents a theoretical model of the major input, team process, and output variables that should be considered during a handoff. THEORETICAL MODEL BACKGROUND: The model integrates three theoretical frameworks that capture the various inputs, processes, and outputs surrounding handoff events through the lens of teamwork. OVERVIEW OF THE MODEL: Specifically, the model describes the environment, organization, people, and tools as inputs. Communication, leadership, coordination, and decision making serve as the processes, and the outputs are the organization, teams, providers, and patients.

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

Anaesthesia handoffs are associated with negative outcomes (e.g. inappropriate treatments, post-operative complications, and in-hospital mortality). To minimise these adverse outcomes, federal bodies (e.g. Joint Commission) have mandated handoff standardisation. Due to the proliferation of handoff interventions and research, there is a need to meta-analyze anaesthesia handoffs. Therefore, we performed meta-analyses on the provider, patient, organisational, and handoff outcomes related to post-operative anaesthesia handoff protocols. We meta-analysed 41 articles with post-operative anaesthesia handoffs that implemented a standardised handoff protocol. Compared to no standardisation, a standardised post-operative anaesthesia handoff changed provider outcomes with an OR of 4.03 (95% CI 3.20-5.08), patient outcomes with an OR of 1.49 (95% CI 1.32-1.69), organisational outcomes with an OR of 4.25 (95% CI 2.51-7.19), handoff outcomes with an OR of 8.52 (95% CI 7.05-10.31). Our meta-analyses demonstrate that standardised post-operative anaesthesia handoffs altered patient, provider, organisational, and handoff outcomes. Practitioner Summary: We conducted meta-analyses to assess the effects of post-operative anaesthesia handoff standardisation on provider, patient, organisational, and handoff outcomes. Our findings suggest that standardised post-operative anaesthesia handoffs changed all listed outcomes in a positive direction. We discuss the implications of these findings as well as notable limitations in this literature base.

Human Factors and Ergonomics in Healthcare: Industry Demands and a Path Forward.

This article reviews three industry demands that will impact the future of Human Factors and Ergonomics in Healthcare settings. These demands include the growing population of older adults, the increasing use of telemedicine, and a focus on patient-centered care. Following, we discuss a path forward through improved medical teams, error management, and safety testing of medical devices and tools. Future challenges are discussed.

Impact of alarm management and automation on abnormal operations: A human-in-the-loop simulation study.

Process control consists of complex states of performance that require a significant amount of operator attention and skill to manage. Automation and smart alarms can enhance these processes. This study investigated the effects of alarm management and automation on process control operator workload (NASA-TLX) and performance via material lost through flaring outcomes. Eleven console qualified operators participated in a human-in-the-loop, high-fidelity simulation-based training exercise. Three levels of alarm management (no rationalization, rationalization, and state-based smart alarm) and two levels of automation (no automation and automation) conditions were implemented using six scenarios. A repeated measures two-way MANOVA indicated that both alarm management schema and automation significantly affected operator workload and performance. These results indicate that state-based smart alarm management and automation schemas may assist operators in reducing workload and material lost through flare release during abnormal operating conditions.

A Bayesian Approach on Investigating Helicopter Emergency Medical Fatal Accidents.

INTRODUCTION: Helicopter Emergency Medical Service (HEMS) is a mode of transportation designed to expedite the transport of a patient. Compared to other modes of emergency transport and other areas of aviation, historically HEMS has had the highest accident-related fatality rates. Analysis of these accident data has revealed factors associated with an increased likelihood of accident-based fatalities. Here we report the results of an analysis on the likelihood of a fatality based on various factors as a result of a HEMS accident, employing a Bayesian framework.METHODS: A retrospective study was conducted using data extracted from the NTSB aviation accident database from April 31, 2005, to April 26, 2018. Evidence from Baker et al. (2006) was also used as prior information spanning from January 1, 1983, to April 30, 2005.RESULTS: A Bayesian logistic regression was implemented using the prior information and current data to calculate a posterior distribution confidence interval of possible values in predicting accident fatality. The results of the model indicate that flying at night (OR 3.06; 95 C.I 2.14, 4.48; PoD 100), flying under Instrument Flight Rules (OR 7.54; 95 C.I 3.94, 14.44; PoD 100), and post-crash fires (OR 18.73; 95 C.I 10.07, 34.12; PoD 100) significantly contributed to the higher likelihood of a fatality.CONCLUSION: Our results provide a comprehensive analysis of the most influential factors associated with an increased likelihood of a fatal accident occurring. We found that over the past 35 yr these factors were consistently associated with a higher likelihood of a fatality occurring.Simonson RJ, Keebler JR, Chaparro A. A Bayesian approach on investigating helicopter emergency medical fatal accidents. Aerosp Med Hum Perform. 2021; 92(7):563569.

Telerounding: A scoping review and implications for future healthcare practice.

Introduction: Telerounding is slated to become an important avenue for future healthcare practice. As utilization of telerounding is increasing, a review of the literature is necessary to distill themes and identify critical considerations for the implementation of telerounding. We provide evidence of the utility of telerounding and considerations to support its implementation in future healthcare practice based on a scoping review. Method: We collected articles from nine scientific databases from the earliest dated available articles to August 2020. We identified whether each article centered on telerounding policies, regulations, or practice. We also organized information from each article and sorted themes into four categories: sample characteristics, technology utilized, study constructs, and research outcomes. Results: We identified 21 articles related to telerounding that fit our criteria. All articles emphasized telerounding practice. Most articles reported data collected from surgical wards, had adult samples, and utilized robotic telerounding systems. Most articles reported null effects or positive effects on their measured variables. Discussion: Providers and patients can benefit from the effective implementation of telerounding. Telerounding can support patient care by reducing travel expenses and opportunities for infection. Evidence suggests that telerounding can reduce patient length of stay. Patients and providers are willing to utilize telerounding, but patient willingness is influenced by age and education. Telerounding does not appear to negatively impact satisfaction or patient care. Organizations seeking to implement telerounding systems must consider education for their providers, logistics associated with hardware and software, scheduling, and characteristics of the organizational context that can support telerounding. Considerations provided in this article can mitigate difficulties associated with the implementation of telerounding.

Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety.

ABSTRACT: Suboptimal exchange of information can have tragic consequences to patient's safety and survival. To this end, the Joint Commission lists communication error among the most common attributable causes of sentinel events. The risk management literature further supports this finding, ascribing communication error as a major factor (70%) in adverse events. Despite numerous strategies to improve patient safety, which are rooted in other high reliability industries (e.g., commercial aviation and naval aviation), communication remains an adaptive challenge that has proven difficult to overcome in the sociotechnical landscape that defines healthcare. Attributing a breakdown in information exchange to simply a generic "communication error" without further specification is ineffective and a gross oversimplification of a complex phenomenon. Further dissection of the communication error using root cause analysis, a failure modes and effects analysis, or through an event reporting system is needed. Generalizing rather than categorizing is an oversimplification that clouds clear pattern recognition and thereby prevents focused interventions to improve process reliability. We propose that being more precise when describing communication error is a valid mechanism to learn from these errors. We assert that by deconstructing communication in healthcare into its elemental parts, a more effective organizational learning strategy emerges to enable more focused patient safety improvement efforts. After defining the barriers to effective communication, we then map evidence-based recovery strategies and tools specific to each barrier as a tactic to enhance the reliability and validity of information exchange within healthcare.

Team Combat Identification: Effects of Gender, Spatial Visualization, and Disagreement.

OBJECTIVE: The combat identification (CID) abilities of same-gender and mixed-gender dyads were experimentally assessed, along with measures of spatial skills and team communication. BACKGROUND: CID is a high-stakes decision-making task involving discrimination between friendly and enemy forces. Literature on CID is primarily focused on the individual, but the extensive use of teams in the military means that more team-based research is needed in this area. METHOD: After a set of training sessions, 39 dyads were tasked with identifying 10 armored vehicles in a series of pictures and videos. Team communication was recorded, transcribed, and coded for instances of disagreements. RESULTS: Analyses indicated that males scored higher on a spatial visualization measure than did females. M-M teams performed significantly better than M-F teams on the CID task, but when spatial ability and team disagreements were added as predictors, the effect of team gender composition became nonsignificant. Spatial ability and team disagreement were significant predictors of team CID performance. CONCLUSION: Results suggest that spatial skills and team disagreement behaviors are more important for team CID performance than a team's gender composition. To our knowledge, this is the first lab study of team CID. APPLICATION: This research highlights the importance of understanding both individual differences (e.g., spatial skills) and team processes (e.g., communication) within CID training environments in the military context.

An Event-based Approach to Measurement: Facilitating Observational Measurement in Highly Variable Clinical Settings.

BACKGROUND: Translational research in medical education requires the ability to rigorously measure learner performance in actual clinical settings; however, current measurement systems cannot accommodate the variability inherent in many patient care  environments. This is especially problematic in emergency medicine, where patients represent a wide spectrum of severity for a single clinical presentation. Our objective is to describe and implement EBAM, an event-based approach to measurement that can be applied to actual emergency medicine clinical events. METHODS: We used a four-step event-based approach to create an emergency department trauma resuscitation patient care measure. We applied the measure to a database of 360 actual trauma resuscitations recorded in a Level I trauma center using trained raters. A subset (n = 50) of videos was independently rated in duplicate to determine inter-rater reliability. Descriptive analyses were performed to describe characteristics of resuscitation events and Cohen's kappa was used to calculate reliability. RESULTS: The methodology created a metric containing both universal items that are applied to all trauma resuscitation events and conditional items that only apply in certain situations. For clinical trauma events, injury severity scores ranged from 1 to 75 with a mean (±SD) of 21 (±15) and included both blunt (254/360; 74%) and penetrating (86/360; 25%) traumatic injuries, demonstrating the diverse nature of the clinical encounters. The mean (±SD) Cohen's kappa for patient care items was 0.7 (±0.3). CONCLUSION: We present an event-based approach to performance assessment that may address a major gap in translational education research. Our work centered on assessment of patient care behaviors during trauma resuscitation. More work is needed to evaluate this approach across a diverse array of clinical events.

Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors.

Lack of verification is often cited as a root cause of medication errors; however, medication errors occur in spite of conventional verification practices and it appears that human factors engineering (HFE) can inform the design of a more effective method. To this end, an HFE-driven process was designed and implemented in an urban, Midwestern emergency medical service agency. Medication error data were collected over a 54-month period, 27 months before and after implementation. A decrease in the average monthly error rate was realized for all medications administered (49.0%) during the post-intervention time period. The average monthly error rate for fentanyl, a commonly administered analgesic, demonstrated a 71.1% error rate decrease. This study is the first to evaluate the effectiveness of a team-based cross-check process for medication verification to prevent errors in the prehospital setting.

Considerations for Multiteam Systems in Emergency Medical Services.

OBJECTIVE: Despite good intentions, mishaps in teamwork continue to affect patient's lives and plague the medical community at large and Emergency Medical Services (EMS) in particular. Effective and efficient management of patient care necessitates that sets of multiple teams (i.e., multiteam systems [MTSs] - EMS ground crews, EMS air crews, dispatch, and receiving hospital teams) seamlessly work together. Although advances have been made to improve teams, little research has been dedicated to enhancing MTSs especially in the critical yet often under studied domain of EMS. The purpose of this paper is to assist the pre-hospital community in strengthening patient care by presenting considerations unique to multiteam systems. METHODS: We synthesized the literature pertinent to multi-team systems and emergency medical services. RESULTS: From this synthesis, we derived five unique considerations: goals, boundary spanning, adaptation, leadership, and social identity. CONCLUSIONS: MTSs are prevalent in prehospital care, as they define how multiple component healthcare teams work together to intervene in emergency situations. We provided some initial directions regarding considerations for success in EMS MTSs based on existing research, but we also recognize the need for further study on these issues.

Human Factors Applied to Perioperative Process Improvement.

This article discusses some of the major theories of the science of human factors/ergonomics (HF/E) in relation to perioperative medicine, with a focus on safety and errors within these systems. The discussion begins with human limitations based in cognition, decision making, stress, and fatigue. Given these limitations, the importance of measuring human performance is discussed. Finally, using the HF/E perspective on safety, high-level recommendations are provided for increasing safety within the perioperative environment.

Shifts in Maximum Audiovisual Integration with Age.

Listeners attempting to understand speech in noisy environments rely on visual and auditory processes, typically referred to as audiovisual processing. Noise corrupts the auditory speech signal and listeners naturally leverage visual cues from the talker's face in an attempt to interpret the degraded auditory signal. Studies of speech intelligibility in noise show that the maximum improvement in speech recognition performance (i.e., maximum visual enhancement or VEmax), derived from seeing an interlocutor's face, is invariant with age. Several studies have reported that VEmax is typically associated with a signal-to-noise (SNR) of -12 dB; however, few studies have systematically investigated whether the SNR associated with VEmax changes with age. We investigated if VEmax changes as a function of age, whether the SNR at VEmax changes as a function of age, and what perceptual/cognitive abilities account for or mediate such relationships. We measured VEmax on a nongeriatric adult sample (N=64) ranging in age from 20 to 59 years old. We found that VEmax was age-invariant, replicating earlier studies. No perceptual/cognitive measures predicted VEmax, most likely due to limited variance in VEmax scores. Importantly, we found that the SNR at VEmax shifts toward higher (quieter) SNR levels with increasing age; however, this relationship is partially mediated by working memory capacity, where those with larger working memory capacities (WMCs) can identify speech under lower (louder) SNR levels than their age equivalents with smaller WMCs. The current study is the first to report that individual differences in WMC partially mediate the age-related shift in SNR at VEmax.