from HFES:

The Human Factors and Ergonomics Society is proud to announce the Human Factors Prize, established in 2010 by Editor-in-Chief William S. Marras. The prize, which will be presented for the first time in 2011, recognizes excellence in HF/E research through an annual competition in which authors are invited to submit papers on a specific topic for that year. The topic is selected by the editor in chief in consultation with a Board of Referees chaired by Immediate Past Human Factors Editor Nancy J. Cooke. See below for the current year’s topic.

The prize carries a $10,000 cash award and publication of the winning paper in the Society’s flagship journal, Human Factors. The award will be formally conferred at a special session at the HFES Annual Meeting, where the recipient will present his or her work.

2011 Topic
The topic for the inaugural-year Prize is health care ergonomics. Health care ergonomics is broadly defined to include research at the intersection of health care and human factors. Suitable sample topics include human factors aspects of home health care, the ergonomics of laparoscopic equipment and procedures, patient care coordination, usability of electronic health records and informatics, macroergonomics of health care facilities, and use of simulation for health care training.

New Years Day is always a time for reflection on the accomplishments of the past year and a stimulus to plan for the upcoming months.

Here’s some Safety new years resolution ideas from the World Health Organization. See how they compare with your organization’s and your own personal safety priorities.

The top three priorities in research for global patient safety:

• Adverse Drug events and Medication Errors
• Adverse Medical Device events (the dog smells usability issues in this one)
• Care of the Frail and Elderly

Others on the list of particular interest to this blog and IO psychologists:

• 6. Devices that lack “human factors” considerations built into their design and modus of operandi
• 10. Impact of work pressure on patient safety
• 12. Inadequate manpower
• 15. Lack of appropriate knowledge and transfer of knowledge
• 16. Lack of communication and coordination
• 23. Procedures that lack human factors consideration built into design and operandi
• 24. Role of safety culture
• 26. Stress and Fatigue
• 27. Surgical errors

WHO has 28 safety research recommendations: Read the rest here

I can’t post about this topic enough (usability and safety) and I can’t say it better than Dr. Nancy Staggers from the University of Maryland. Please read her article from the Online Journal of Nursing Informatics. (By the way, this journal is a free online publication that hosts articles from many nursing visionaries. Click to read current issue)

The opening quote from the article:
Usability has a strong, often direct relationship with clinical
productivity, error rate, user fatigue, and user satisfaction–
critical to EMR adoption
(HIMSS, 2009)

Staggers, N. (October, 2010). The Rapidly Emerging National Interest in HIT Usability. Online Journal of Nursing Informatics (OJNI),14 (3).

Boston hospital made 3 spine operation errors

On Friday December 24, 2010, 10:12 am EST
BOSTON (AP) — A major Boston teaching hospital has been cited by federal and state health inspectors after doctors operated on the wrong location on three spine surgery patients.
All three unconnected errors happened since September.
Dr. Kenneth Sands is the senior vice president of health care quality at Beth Israel Deaconess Medical Center. He tells The Boston Globe the surgeons apparently miscounted the patients’ vertebrae and operated directly above or below where they were supposed to.
Two operations were conducted by the same surgeon. The hospital did not release names. The hospital has procedures in place to avoid errors, and those procedures have been improved.
Sands says none of the patients suffered harmful effects as a result of the mistaken surgery. But a lawyer for one says the woman has experienced problems. Information from: The Boston Globe, http://www.boston.com/globe

Safetydog Comment: When two different surgeons and their teams (and one twice) make an error it is imperative to look at the team process. I think we have to look at the timing of checklists. It seems time out at the onset of an OR procedure is not enough. A time out needs to be repeated before every irreversible cut.
Human Factors can be used to determine when in a process some kind of alert has to occur when that should be a human alert or a technology produced alert. Rather than just copy best practices, hospitals need to review their current practices, reduce unnecessary steps and then identify areas in the process where a reminder or alert should take place. Timing is key. There are always points in a process after which there is no resiliency.

from the Las Vegas Sun:
“Reform is slow in coming because hospitals and doctors are not directly accountable — financially — to patients and provide little transparency, said Haskell, who was named one of the “100 Most Powerful People in Healthcare” in 2009 by Modern Healthcare magazine.
“The customer doesn’t pay directly, and they (hospitals and doctors) keep everything to do with price and quality secret,” she said.
John James, a Houston toxicologist, lost his son in 2002 when Read the rest of this entry »

I recently received an email asking to highlight another website on my blog. This site DrugWatch is an A-Z listing of medications, side effects, latest news and uses. There is also a section on lawsuits against particular drugs. This section is particularly appropriate since this site is run by a lawfirm that specializes in personal injury protection (Peterson Firm, LLC). This is clearly delineated on their website banner. The major pharmaceutical companies have their websites and commercials informing the public about “diseases” and drugs that can treat them and the lawyers have their websites about all the side effects of these treatments. Here are the current drugs people are searching for on the lawyers’ website: Read the rest of this entry »

A thought provoking power point from Vera Sharav who is the founder of the Alliance for Human Research Protection. This brings up the fundamental question in today’s society: in terms of safety, who or what do we believe?
Is there such a thing as an unbiased person or agency?
Given human factors issues of bias, is research really unbiased? How do we know experts are really experts? How do we know safety practices are really supported and followed in hospitals, airlines, oil drilling and other high risk industries? Have regulatory inspections shown to truly increase safety or do they encourage organizations to hide their dirty laundry?
How can we use the concept of transparency to improve the accuracy of the data that is presented in site visits, publications and quality metric reporting?

Scientific fraud article from the same group

10 Million patients later:The case of Darvocet. How long was this drug on the market before being seriously reviewed 😦

Are you looking for information about:
Risk and Quality Resources
Medical Technology
Patient Safety Organization
Hazard & Recall Management

The ECRI is a non-profit evidence based practice center that uses scientific inquiry to look at medical procedures, devices and drugs.
Some of their topics this year included the Baxter pump recall and alarm fatigue.

A new article in NEJM:
“In conclusion, harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care. Since North Carolina has been a leader in efforts to improve safety, a lack of improvement in this state suggests that further improvement is also needed at the national level. Although the absence of large-scale improvement is a cause for concern, it is not evidence that current efforts to improve safety are futile. On the contrary, data have shown that focused efforts to reduce discrete harms, such as nosocomial infections10,36 and surgical complications,37 can significantly improve safety. However, achieving transformational improvements in the safety of health care will require further study of which patient-safety efforts are truly effective across settings and a refocusing of resources, regulation, and improvement initiatives to successfully implement proven interventions.”