A human factors subsystems approach to trauma care.

IMPORTANCE: A physician-centered approach to systems design is fundamental to ameliorating the causes of many errors, inefficiencies, and reliability problems. OBJECTIVE: To use human factors engineering to redesign the trauma process based on previously identified impediments to care related to coordination problems, communication failures, and equipment issues. DESIGN, SETTING, AND PARTICIPANTS: This study used an interrupted time series design to collect historically controlled data via prospective direct observation by trained observers. We studied patients from a level I trauma center from August 1 through October 31, 2011, and August 1 through October 31, 2012. INTERVENTIONS: A range of potential solutions based on previous observations, trauma team engagement, and iterative cycles identified the most promising subsystem interventions (headsets, equipment storage, medication packs, whiteboard, prebriefing, and teamwork training). Five of the 6 subsystem interventions were successfully deployed. Communication headsets were found to be unsuitable in simulation. MAIN OUTCOMES AND MEASURES: The primary outcome measure was flow disruptions, with treatment time and length of stay as secondary outcome measures. RESULTS: A total of 86 patients were observed before the intervention and 120 after the intervention. Flow disruptions increased if the patient had undergone computed tomography (CT) (F1200 = 20.0, P < .001) and had been to the operating room (F1200 = 63.1, P < .001), with an interaction among the intervention, trauma level, and CT (F1200 = 6.50, P = .01). For total treatment time, there was an effect of the intervention (F1200 = 21.7, P < .001), whether the patient had undergone CT (F1200 = 43.0, P < .001), and whether the patient had been to the operating room (F1200 = 85.8, P < .001), with an interaction among the intervention, trauma level, and CT (F1200 = 15.1, P < .001), reflecting a 20- to 30-minute reduction in time in the emergency department. Length of stay was reduced significantly for patients with major mortality risk (P = .01) from a median of 8 to 5 days. CONCLUSIONS AND RELEVANCE: Deployment of complex subsystem interventions based on detailed human factors engineering and a systems analysis of the provision of trauma care resulted in reduced flow disruptions, treatment time, and length of stay.

Integrating human factors research and surgery: a review.

OBJECTIVE: To provide a review of human factors research within the context of surgery. DATA SOURCES: We searched PubMed for relevant studies published from the earliest available date through February 29, 2012. STUDY SELECTION: The search was performed using the following keywords: human factors, surgery, errors, teamwork, communication, stress, disruptions, interventions, checklists, briefings, and training. Additional articles were identified by a manual search of the references from the key articles. As 2 human factors specialists, a senior clinician, and a junior clinician, we carefully selected the most appropriate exemplars of research findings with specific relevance to surgical error and safety. DATA EXTRACTION: Seventy-seven articles of relevance were selected and reviewed in detail. Opinion pieces and editorials were disregarded; the focus was solely on articles based on empirical evidence, with a particular emphasis on prospectively designed studies. DATA SYNTHESIS: The themes that emerged related to the development of human factors theories, the application of those theories within surgery, a specific interest in the concept of flow, and the theoretical basis and value of human-related interventions for improving safety and flow in surgery. CONCLUSIONS: Despite increased awareness of safety, errors routinely continue to occur in surgical care. Disruptions in the flow of an operation, such as teamwork and communication failures, contribute significantly to such adverse events. While it is apparent that some incidence of human error is unavoidable, there is much evidence in medicine and other fields that systems can be better designed to prevent or detect errors before a patient is harmed. The complexity of factors leading to surgical errors requires collaborations between surgeons and human factors experts to carry out the proper prospective and observational studies. Only when we are guided by this valid and real-world data can useful interventions be identified and implemented.