Archive for September, 2010|Monthly archive page

Read it: “Crisis Management in Acute Care Settings”

In Human Factors, Patient Safety on September 8, 2010 at 12:06 pm

Crisis Management in Acute Care Settings by Pierre, Hofinger, and Buershaper (2008).

This is one of those books that I find so relevant I have read it several times and own the hardcover, the paperback and the Kindle version. I have referred to it numerous times in papers and conversations. It is a short book at 227 pages but every page is filled with amazing material.

The preface to the book begins with the quote “All of life is problem solving” (Popper). Since they say it better than I, here are excerpts from the authors’ words describing what this book is about:
On a regular basis, healthcare professionals are faced with problems that are sudden, unexpected and pose a threat to a patient’s life. Worse still, these problems do not leave much time for… Read the rest of this entry »

Human Factors and Ergonomic Studies

In Patient Safety on September 7, 2010 at 9:58 pm

In the future I am hoping to plan a research project involving human factors and ergonomics and nursing care delivery. One of the tools I hope to use is the device known as The Bodymedia Fit Armband. This device is worn 24 hours a day on one’s upper arm. It collects data
by using an accelerometer to count steps, skin temperature and galvanic skin response to measure body heat and activity, and heat flux to measure the heat your body gives off to the environment (Bodymedia, 2008)….Read more

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Comments on a failure

In Patient Safety on September 6, 2010 at 9:45 pm

The IHI collects thoughts on the issue of the error of wrong sided surgery.

What is the link between Human Factors Theory and cheese?

In Human Factors on September 6, 2010 at 6:32 pm

In the previous post Some Fun with Human Factors we looked at a maze with a mouse trying to get to the cheese to illustrate how confusing it can be navigate the many user interfaces one encounters in a typical hospital workday. Now onto to another cheese analogy in Human Factors: James Reason’s Model of Accident Causation.


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In Patient Safety on September 6, 2010 at 3:59 pm

Here is a blog developed to let patients speak about unsatisfactory experiences with the healthcare system. Their experiences are described as well as suggestions for improvement.  Read through the stories to see if what they experienced could also happen in your environment.

Patient Safety Blog -Telling our Stories The purpose of the blog created in 2007 is ” … to teach and encourage patients and patient advocates to become knowledgeable, pro-active, and empowered partners with their doctors and nurses. The website provides unbiased advice to keep our parents, children and other loved ones with acute or chronic illnesses healthy and safe from medical errors (Farbstein, 2007).” The blog is run by Ken Farbstein.

Rapid Response, MEWS and PEWS

In Checklists, Patient Safety on September 6, 2010 at 3:40 pm

Many Rapid Response teams have been formed in hospitals as a result of the IHI’s 5 million Lives campaign. Early warning system tools are also a recommendation along these lines to help identify when activate the Rapid Response Team. One hospital in Wales has developed MEWS* (Modified Early Warning System). The MEWS consists of a scoring tool and interventions based on these scores in assessing a deteriorating adult patient. View the MEWS. The tool is compact in that the scores in the middle show zero for normal then go out to the left as 1-2-3 for parameters that are dangerously low and out to the right as 1-2-3 for parameters that are dangerously high. Interventions for scores are listed at the bottom. This is a user friendly all-in-one algorithm/flowchart template for a safety assessment tool….. Read the rest of this entry »

Some fun with Human Factors

In Human Factors on September 5, 2010 at 2:37 pm

In a hospital environment there are many different computer programs and machines for employees to master. For medication administration alone a hospital may have a high volume IV pump, a PCA (patient controlled analgesia) pump, a syringe pump and an epidural pump. The ER may have one computer system, the OR another, the inpatient units another… Often all these are not from a single manufacturer and thus can have wildly different user interfaces. Does training alone provide enough support?
The following shows how frustrating this situation can be. How many levels can you pass when you have to learn a new mapping at each level?? Start now 🙂

The BP Oil spill and Normal Accident Theory

In Normal Accident Theory on September 5, 2010 at 2:37 pm

If we believe in Normal Accident Theory (NAT) should we focus on prevention but also expect failure ?

NAT and the BP oil spill excerpt from Culturing Science blog:
“We are all human. We all know what it’s like to procrastinate, to forget to leave a message, to have our minds wander. In his book, Chiles argues, citing over 50 examples in immense detail, that most disasters are caused by “ordinary mistakes” – and that to live in this modern world, we have to “acknowledge the extraordinary damage that ordinary mistakes can now cause.” Most of the time, things run smoothly. But when they don’t, our culture requires us to find someone to blame instead of recognizing that our own lifestyles cause these disasters. Instead of reconsidering the way we live our lives, we simply dump our frustration off so that we can continue living our lives in comfort (Waters, 2010).”

Where is the best place to direct resources to truly improve safety? (continued…)
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Berwick, Pronovost and Wachter

In Patient Safety on September 4, 2010 at 6:10 pm

A call for new safetydogs from Wachter’s blog:

“…I fear that it means that the business case to improve quality and safety has not yet reached the point where full engagement by healthcare organizations and caregivers isn’t dependent on the personal engagement of individuals with unique leadership and communication skills. We’ll know it has when states and CEOs are asking – even begging – Peter to help them prevent ICU infections, and when IHI and similar organizations are being tapped constantly for help, even if the answer to the predictable question, “Can Don come to our hospital to kick off our initiative?,” is always “no.”

We’re blessed to have the likes of Pronovost and Berwick in the quality and safety arena – we’d never have gotten to where we are today without them. But we’ll know that we have truly arrived when we no longer depend on them to get the work done.”

Read this full posting on Wachter’s site

Pat Tillman and Fratricide

In Human Factors on September 3, 2010 at 9:52 pm

Pat Tillman was an NFL player who left to join the military with his brother. His death was portrayed in high drama as an example of military heroism only to find out later it was a case of fratricide. Pat like many others was a hero but his death could have been prevented. The military uses human factors theory in the investigations of fratricides which are incidents commonly known as “friendly fire.” If anyone sees the new Tillman movie, The Tillman Story and is interested in this topic as it applies to the military here is an example of some investigations: Read Webb & Hewitt, 2010
While this is a study related to combat, its applicability to any high stakes environment is evident. Also interesting are their findings of teamwork and in particular the leadership of the team being implicated in occurrences of fratricide…. Read the rest of this entry »

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