Human factors error and patient monitoring

Enhancing the Usability of Patient Monitoring Devices in Intensive Care Units: Usability Engineering Processes for Early Warning System (EWS) Evaluation and Design

Background/Objectives: This study aimed to enhance the usability of patient monitoring systems by integrating the Early Warning Score (EWS) function and improving user interface elements. The EWS function is expected to enable the early detection of acute deterioration and prompt medical intervention, while the optimized design supports rapid decision-making by nursing staff. Methods: Two formative usability evaluations were conducted to identify user requirements and improve the device design. A simulated usability test involved five ICU medical staff members, followed by a user preference survey with 72 ICU staff members in a real clinical setting. After incorporating feedback, a summative usability test with 23 ICU nurses was performed to evaluate the revised device. Results: Issues related to unfamiliar parameter terminology and alarm message positioning were identified, and the need for the EWS function was emphasized. The summative evaluation showed an increase in task success rate from 86% to 90% and a significant improvement in user satisfaction from 74.85 (SD: 0.88) to 89.55 (SD: 0.75) (p < 0.05). Conclusions: The integration of the EWS function and interface improvements significantly enhanced the usability of patient monitoring system. These advancements are expected to enable rapid detection of patient deterioration and support timely clinical decision-making by ICU staff.

User Experience Study of the Patient Monitoring Systems Based on Usability Testing and Eye Tracking

BACKGROUND/OBJECTIVES

The patient monitoring system is a critical tool commonly used in hospitals, making it essential to assess caregivers' user requirements and satisfaction with its usability. In intensive care units (ICUs), the usability of these systems is closely linked to the work efficiency of key users, such as nurses, and directly impacts patient safety and treatment outcomes. This study evaluates the usability of patient monitoring systems in intensive care units (ICUs), focusing on user requirements and satisfaction among nurses, the primary users. Usability is directly linked to work efficiency and patient safety, with post-marketing surveillance (PMS) data from overseas, highlighting issues such as unrecognized alarms, leading to worsened patient conditions.

METHODS

This study involved 22 ICU nurses who had used the system for over a year, assessing usability through testing, satisfaction surveys, the Health-ITUES, and eye-tracking analysis.

RESULTS

The results showed a high success rate (94%) and positive satisfaction scores (4.15, SD = 0.88), with a Health-ITUES score of 4.13 (SD = 0.78). Eye tracking revealed that some functions, including alarms, were overlooked or not recognized.

CONCLUSIONS

Recommendations include improving the interface for alarm messages and recording deletion functions to enhance user satisfaction and patient safety.

Mitigating data quality challenges in ambulatory wrist-worn wearable monitoring through analytical and practical approaches

Chronic disease management and follow-up are vital for realizing sustained patient well-being and optimal health outcomes. Recent advancements in wearable technologies, particularly wrist-worn devices, offer promising solutions for longitudinal patient monitoring, replacing subjective, intermittent self-reporting with objective, continuous monitoring. However, collecting and analyzing data from wearables presents several challenges, such as data entry errors, non-wear periods, missing data, and wearable artifacts. In this work, we explore these data analysis challenges using two real-world datasets (mBrain21 and ETRI lifelog2020). We introduce practical countermeasures, including participant compliance visualizations, interaction-triggered questionnaires to assess personal bias, and an optimized pipeline for detecting non-wear periods. Additionally, we propose a visualization-oriented approach to validate processing pipelines using scalable tools such as tsflex and Plotly-Resampler. Lastly, we present a bootstrapping methodology to evaluate the variability of wearable-derived features in the presence of partially missing data segments. Prioritizing transparency and reproducibility, we provide open access to our detailed code examples, facilitating adaptation in future wearable research. In conclusion, our contributions provide actionable approaches for improving wearable data collection and analysis.

Anesthesia personnel’s visual attention regarding patient monitoring in simulated non-critical and critical situations, an eye-tracking study

Background

Cognitive ergonomics design of patient monitoring may reduce human factor errors in high-stress environments. Eye-tracking is a suitable tool to gain insight into the distribution of visual attention of healthcare professionals with patient monitors, which may facilitate their further development.

Methods

This prospective, exploratory, high-fidelity simulation study compared anesthesia personnel’s visual attention (fixation count and dwell-time) to 15 areas of interest on the patient monitor during non-critical and critical anesthesia situations. Furthermore, we examined the extent to which participants’ experience influenced visual attention and which vital signs displayed on the patient monitor received the most visual attention. We used mixed zero-inflated Poisson regression and mixed linear models to analyze the data.

Results

Analyzing 23 ten-minute scenarios, we found significantly more fixations to the areas of interest on the patient monitor during critical than non-critical situations (rate ratio of 1.45; 95% CI 1.33 to 1.59; p < 0.001). However, the dwell-time on the areas of interest did not significantly differ between the non-critical and critical situations (coefficient of − 1.667; 95% CI − 4.549 to 1.229; p = 0.27). The professional experience did not significantly influence the visual attention (fixation: rate ratio of 0.88; 95% CI 0.54 to 1.43; p = 0.61 and dwell-time: coefficient of 0.889; 95% CI − 1.465 to 3.229; p = 0.27).

Over all situations, anesthesia personnel paid the most attention to the vital signs blood pressure (fixation: mean [SD] of 108 [74.83]; dwell-time: mean [SD] of 27 [15.90] seconds), end-expiratory carbon dioxide (fixation: mean [SD] of 59 [47.39]; dwell-time: mean [SD] of 30 [21.51] seconds), and the electrocardiogram (fixation: mean [SD] of 58 [64.70]; dwell-time: mean [SD] of 15 [14.95] seconds).

Conclusions

Critical anesthesia situations increased anesthesia personnel’s visual interaction with the patient monitor. Furthermore, we found that their visual attention focused mainly on a few vital signs. To assist clinicians in critical situations, manufacturers should optimize monitors to convey necessary information as easily and quickly as possible and optimize the visibility of less frequently observed but equally critical vital signs, especially when they are in an abnormal range.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01705-6.

Augmenting Critical Care Patient Monitoring Using Wearable Technology: Review of Usability and Human Factors

Background

Continuous monitoring of the vital signs of critical care patients is an essential component of critical care medicine. For this task, clinicians use a patient monitor (PM), which conveys patient vital sign data through a screen and an auditory alarm system. Some limitations with PMs have been identified in the literature, such as the need for visual contact with the PM screen, which could result in reduced focus on the patient in specific scenarios, and the amount of noise generated by the PM alarm system. With the advancement of material science and electronic technology, wearable devices have emerged as a potential solution for these problems. This review presents the findings of several studies that focused on the usability and human factors of wearable devices designed for use in critical care patient monitoring.

Objective

The aim of this study is to review the current state of the art in wearable devices intended for use by clinicians to monitor vital signs of critical care patients in hospital settings, with a focus on the usability and human factors of the devices.

Methods

A comprehensive literature search of relevant databases was conducted, and 20 studies were identified and critically reviewed by the authors.

Results

We identified 3 types of wearable devices: tactile, head-mounted, and smartwatch displays. In most cases, these devices were intended for use by anesthesiologists, but nurses and surgeons were also identified as potentially important users of wearable technology in critical care medicine. Although the studies investigating tactile displays revealed their potential to improve clinical monitoring, usability problems related to comfort need to be overcome before they can be considered suitable for use in clinical practice. Only a few studies investigated the usability and human factors of tactile displays by conducting user testing involving critical care professionals. The studies of head-mounted displays (HMDs) revealed that these devices could be useful in critical care medicine, particularly from an ergonomics point of view. By reducing the amount of time the user spends averting their gaze from the patient to a separate screen, HMDs enable clinicians to improve their patient focus and reduce the potential of repetitive strain injury.

Conclusions

Researchers and designers of new wearable devices for use in critical care medicine should strive to achieve not only enhanced performance but also enhanced user experience for their users, especially in terms of comfort and ease of use. These aspects of wearable displays must be extensively tested with the intended end users in a setting that properly reflects the intended context of use before their adoption can be considered in clinical settings.

Application of Cardio-Forecasting for Evaluation of Human-Operator Performance

The paper presents the results of the development of the cardio-forecasting technology, which introduces a new method to monitor the state of human-operator, which is characteristic for the given production conditions and for individual operators, to predict the moment of exhaustion of his/her working capacity. The work aims to demonstrate the unique, distinctive features of the cardio-forecasting technology for predicting an individual limit of his/her working capacity for each person. A unique methodology for predicting individually for each person the moment when he/she reaches the limit of his/her working capacity is based on a spectral analysis of a human phonocardiogram in order to isolate the frequency component located at the heart contraction frequency. The trend of the amplitude of this component is approximated by its model; consequently, the coefficients of the trend model are determined. They include the operator’s operating time until his/her working capacity is exhausted. A methodology for predicting the moment when he/she reaches the limit of his/her working capacity for each person individually and assessment based on this degree of criticality of their condition will be realized as a software application for smartphones using the Android operating system.

Knowledge, behaviours, training and attitudes of nurses during preparation and administration of intravenous medications in intensive care units (ICU). A multicenter Italian study

BACKGROUND

Medication errors can put at risk the life of patients hospitalized in the ICUs. These errors occur more frequently in the ICUs due to their peculiar medical framework. There is not much information about the knowledge, attitudes, behaviours and training needs of the nurses who work in ICUs towards the medication errors.

OBJECTIVE

This study aims at describing the knowledge, attitudes, behaviours and training needs of the Italian nurses who work in ICUs towards the use of IV drugs, and identifying the strategies that nurses can adopt to prevent the occurrence of medication errors.

MATERIALS AND METHODS

Cross-sectional study. The survey was carried out through a self-administrated questionnaire and it was addressed to 529 Italian nurses who work in the ICUs of Southern, Centre and Northern Italy hospitals (average age of the sample 39.9, SD=9.1, 68.1% females). The questionnaire, made of 36 items divided into 7 sections, was validated after the results of the pilot study.

RESULTS

The study highlighted the importance of the role, behaviours and knowledge of the nurses to prevent the medication errors. The results of the multivariate analysis of the multicentre study show a relation among correct behaviours and positive attitudes, even if it is not statistically significant. Worth mentioning is the fact that the achievement of a university degree affects negatively the correct behaviours (OR 0.56, 95% CI 0.34-0.95), as well as the years of work (OR 0.97, 95% CI 0.94-0.99).

CONCLUSIONS

The results of this multicentre study are encouraging. Nurses who have a good command of the English language (sufficient, good, and excellent) dedicate more than an hour per week to the bibliography update. Extending and deepening the knowledge of the nurses in a cyclical way might be an effective strategy to keep a high level of security of the drugs in the ICUs. The study highlighted that almost all the surveyed nurses (93%) are aware that an adequate knowledge of the drugs dosage calculation is essential to reduce the occurrence of medication errors in the drugs preparation phase.

Patient monitoring with Google Glass: a pilot study of a novel monitoring technology

BACKGROUND

Head-mounted devices (HMDs) are of significant interest for applications within medicine, including in anesthesia for patient monitoring. Previous devices trialed in anesthesia for this purpose were often bulky, involved cable tethers, or were otherwise ergonomically infeasible. Google Glass is a modern HMD that is lightweight and solves many of the issues identified with previous HMDs.

AIM

To examine the acceptance of Google Glass as a patient monitoring device in a pediatric anesthesia context at Princess Margaret Hospital for Children, Perth, Australia.

METHODS

We developed a custom-designed software solution for integrating Google Glass into the anesthesia environment, which enabled the device user to continuously view patient monitoring parameters transmitted wirelessly from the anesthesia workstation.

RESULTS

A total of 40 anesthetists were included in the study. Each anesthetist used the device for the duration of a theater list. We found 90% of anesthetists trialing the device agreed that it was comfortable to wear, 86% agreed the device was easy to read, and 82.5% agreed the device was not distracting. In 75% of cases, anesthetists reported unprompted that they were comfortable using the device in theater. Anesthetists reported that they would use the device again in 76% of cases, and indicated that they would recommend the device to a colleague in 58% of cases.

CONCLUSION

Given the pilot nature of this study, we consider these results highly favorable. Anesthetists readily accepted Google Glass in the anesthetic environment, with further enhancements to device software, rather than hardware, now being the barrier to adoption. There are a number of applications for HMDs in pediatric anesthesia.

The neonatal resuscitation program: current recommendations and a look at the future

The Neonatal Resuscitation Program (NRP) consists of an algorithm and curriculum to train healthcare professionals to facilitate newborn infants' transition to extrauterine life and to provide a standardized approach to the care of infants who require more invasive support and resuscitation. This review discusses the most recent update of the NRP algorithm and recommended guidelines for the care of newly born infants. Current challenges in training and assessment as well as the importance of ergonomics in the optimization of human performance are discussed. Finally, it is recommended that in order to ensure high-performing resuscitation teams, members should be selected and retained based on objective performance criteria and frequent participation in realistic simulated clinical scenarios.

The delivery room of the future: the fetal and neonatal resuscitation and transition suite

Despite advances in the understanding of fetal and neonatal physiology and the technology to monitor and treat premature and full-term neonates, little has changed in resuscitation rooms. The authors' vision for the Fetal and Neonatal Resuscitation and Transition Suite of the future is marked by improvements in the amount of physical space, monitoring technologies, portable diagnostic and therapeutic technologies, communication systems, and capabilities and training of the resuscitation team. Human factors analysis will play an important role in the design and testing of the improvements for safe, effective, and efficient resuscitation of the newborn.

Continuously informing vibrotactile displays in support of attention management and multitasking in anesthesiology

OBJECTIVE

A novel vibrotactile display type was investigated to determine the potential benefits for supporting the attention and task management of anesthesiologists.

BACKGROUND

Recent research has shown physiological monitoring and multitasking performance can benefit from displaying patient data via alarm-like tactile notifications and via continuously informing auditory displays (e.g., sonifications). The current study investigated a novel combination of these two approaches: continuously informing tactile displays.

METHOD

A tactile alarm and two continuously informing tactile display designs were evaluated in an anesthesia induction simulation with anesthesiologists as participants. Several performance measures were collected for two tasks: physiological monitoring and anesthesia induction. A multitask performance score equivalently weighted components from each task, normalized across experimental scenarios. Subjective rankings of the displays were also collected.

RESULTS

Compared to the baseline (visual and auditory only) display configuration, each tactile display significantly improved performance in several objective measures, including multitask performance score. The continuously informing display that encoded the severity of patient health into the salience of its signals supported significantly better performance than the other two tactile displays. Contrasting the objective results, participants subjectively ranked the tactile alarm display highest.

CONCLUSION

Continuously informing tactile displays with alarm-like properties (e.g., salience mapping) can better support anesthesiologists' physiological monitoring and multitasking performance under the high task demands of anesthesia induction. Adaptive display mechanisms may improve user acceptance.

APPLICATION

This study can inform display design to support multitasking performance of anesthesiologists in the clinical setting and other supervisory control operators in work domains characterized by high demands for visual and auditory resources.

Extending hierarchical task analysis to identify cognitive demands and information design requirements

While hierarchical task analysis (HTA) is well established as a general task analysis method, there appears a need to make more explicit both the cognitive elements of a task and design requirements that arise from an analysis. One way of achieving this is to make use of extensions to the standard HTA. The aim of the current study is to evaluate the use of two such extensions--the sub-goal template (SGT) and the skills-rules-knowledge (SRK) framework--to analyse the cognitive activity that takes place during the planning and delivery of anaesthesia. In quantitative terms, the two methods were found to have relatively poor inter-rater reliability; however, qualitative evidence suggests that the two methods were nevertheless of value in generating insights about anaesthetists' information handling and cognitive performance. Implications for the use of an extended HTA to analyse work systems are discussed.

Monitoring with head-mounted displays in general anesthesia: a clinical evaluation in the operating room

BACKGROUND

Patient monitors in the operating room are often positioned where it is difficult for the anesthesiologist to see them when performing procedures. Head-mounted displays (HMDs) can help anesthesiologists by superimposing a display of the patient's vital signs over the anesthesiologist's field of view. Simulator studies indicate that by using an HMD, anesthesiologists can spend more time looking at the patient and less at the monitors. We performed a clinical evaluation testing whether this finding would apply in practice.

METHODS

Six attending anesthesiologists provided anesthesia to patients undergoing rigid cystoscopy. Each anesthesiologist performed 6 cases alternating between standard monitoring using a Philips IntelliVue MP70 and standard monitoring plus a Microvision Nomad ND2000 HMD. The HMD interfaced wirelessly with the MP70 monitor and displayed waveform and numerical vital signs data. Video was recorded during all cases and analyzed to determine the percentage of time, frequency, and duration of looks at the anesthesia workstation and at the patient and surgical field during various anesthetic phases. Differences between the display conditions were tested for significance using repeated-measures analysis of variance.

RESULTS

Video data were collected from 36 cases that ranged from 17 to 75 minutes in duration (median 31 minutes). When participants were using the HMD, compared with standard monitoring, they spent less time looking toward the anesthesia workstation (21.0% vs 25.3%, P = 0.003) and more time looking toward the patient and surgical field (55.9% vs 51.5%, P = 0.014). The HMD had no effect on either the frequency of looks or the average duration of looks toward the patient and surgical field or toward the anesthesia workstation.

CONCLUSIONS

An HMD of patient vital signs reduces anesthesiologists' surveillance of the anesthesia workstation and allows them to spend more time monitoring their patient and surgical field during normal anesthesia. More research is needed to determine whether the behavioral changes can lead to improved anesthesiologist performance in the operating room.

Supporting Anesthetic Monitoring through Tactile Display of Physiological Parameters

Breakdowns in anesthetic monitoring are a frequent contributor to critical incidents in the Operating Room (OR). They can be attributed to a lack of effective attention guidance when traditional visual and auditory display methods are used to present patient physiological data. The current experiment therefore examines the effectiveness of tactile displays to better support anesthetic monitoring. Participants played the role of anesthesiologist in a desktop simulation of an OR environment. They were responsible for completing a visually-demanding intubation task while concurrently monitoring and managing a set of physiological parameters which were displayed using traditional methods. Three tactile display designs redundantly communicated the state and dynamics of one critical physiological parameter, blood pressure. Initial results show improved performance on the intubation and monitoring tasks for all tactile display conditions when compared to conditions with visual and auditory displays only. The most effective tactile patterns communicated both current state and trend information for blood pressure. The findings from this study can be applied to the design of tactile displays for monitoring tasks not only in the OR but in other complex, data-rich environments, such as aviation or process control.

Adverse drug events and medication errors in psychiatry: methodological issues regarding identification and classification

Abstract Adverse drug events and medication errors have received extensive study recently in a variety of clinical populations, though compared to many other areas relatively little work has focused on this area in psychiatry, especially with respect to the contribution of error to harm. The goal of this paper is to discuss methodological issues around measurement of medication safety in psychiatric patients. Against the background of a systems approach, a modern perspective of error management is discussed, and a multidimensional procedure for detection and classification of incidents related to the medication process is presented. This method has proven successful in non-psychiatric settings yielding the current best estimate of error rates and providing insight into the underlying causes. While this general approach can be adapted to the psychiatric setting, a number of issues make measurement especially challenging in psychiatry. These include the fluctuating course of psychiatric disorders, reduced patient adherence to the medication process, adverse effects which are often similar to symptoms of the underlying disorder, the frequent use of wide dose intervals depending on the clinical situation, and the presence of many drug-drug interactions. Data collected by means of the presented approach provide a basis for the development of effective strategies to reduce the risk of medication errors and thus improve patient safety in psychiatric care.

The role of expertise research and human factors in capturing, explaining, and producing superior performance

OBJECTIVES

The goal of this article is to identify some of the major trends and findings in expertise research and their connections to human factors.

BACKGROUND

Progress in the study of superior human performance has come from improved methods of measuring expertise and the development of better tools for revealing the mechanisms that support expert performance, such as protocol analysis and eye tracking.

METHODS

We review some of the challenges of capturing superior human performance in the laboratory and the means by which the expert performance approach may overcome such challenges. We then discuss applications of the expert performance approach to a handful of domains that have long been of interest to human factors researchers.

RESULTS

Experts depend heavily on domain-specific knowledge for superior performance, and such knowledge enables the expert to anticipate and prepare for future actions more efficiently. Training programs designed to focus learners' attention on task-related knowledge and skills critical to expert performance have shown promise in facilitating skill acquisition among nonexperts and in reducing errors by experts on representative tasks.

CONCLUSIONS

Although significant challenges remain, there is encouraging progress in domains such as sports, aviation, and medicine in understanding some of the mechanisms underlying human expertise and in structuring training and tools to improve skilled performance.

APPLICATIONS

Knowledge engineering techniques can capture expert knowledge and preserve it for organizations and for the development of expert systems. Understanding the mechanisms that underlie expert performance may provide insights into the structuring of better training programs for improvingskill and in designing systems to support professional expertise.

Abnormal drug responses with adrenaline on an educational paediatric simulator: the measurement of the responses and correction of the pharmacological model parameters

A paediatric simulator (PediaSimtrade mark, Medical Education Technologies, Inc (METI), Florida, US) has been in use at the Bristol Medical Simulation Centre since early 2000. It has proved to be a very effective educational tool. The simulator is a full-sized high fidelity model of a healthy six year old child weighing 20 kg. Administration of adrenaline (epinephrine) to the simulator was found to create an unrealistic clinical response. Correction of this abnormal response was considered extremely important to ensure valid teaching material for adult learners. Comprehensive physiological measurements and dose responses for adrenaline were evaluated in the simulator under steady state conditions. The dose responses from the simulator were compared with those responses that were considered clinically appropriate by a cohort of paediatric anaesthetists. Expert opinion was utilized as no published haemodynamic data are available for adrenaline in a healthy population of children in this age group. The drug parameters were modified using the simulator drug editor. Dose responses were repeated using the modified drug model and again compared to the required responses. This process was repeated until acceptable clinical limits were achieved. The baseline responses for the drug differed significantly from the required responses. The drug model parameters were successfully modified to give the appropriate clinical responses. The improved model for the haemodynamic effects of adrenaline now provides realistic clinical responses, enabling the paediatric simulator to be a more effective educational tool.

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review

OBJECTIVE

To evaluate the performance of a routine incident reporting system in identifying patient safety incidents.

DESIGN

Two stage retrospective review of patients' case notes and analysis of data submitted to the routine incident reporting system on the same patients.

SETTING

A large NHS hospital in England.

POPULATION

1006 hospital admissions between January and May 2004: surgery (n=311), general medicine (n=251), elderly care (n=184), orthopaedics (n=131), urology (n=61), and three other specialties (n=68).

MAIN OUTCOME MEASURES

Proportion of admissions with at least one patient safety incident; proportion and type of patient safety incidents missed by routine incident reporting and case note review methods.

RESULTS

324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% confidence interval 20.3% to 25.5%). 270 (83%) patient safety incidents were identified by case note review only, 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. 110 admissions (10.9%; 9.0% to 12.8%) had at least one patient safety incident resulting in patient harm, all of which were detected by the case note review and six (5%) by the reporting system.

CONCLUSION

The routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in harm. Structured case note review may have a useful role in surveillance of routine incident reporting and associated quality improvement programmes.

Capturing user requirements in medical device development: the role of ergonomics

Measuring and fulfilling user requirements during medical device development will result in successful products that improve patient safety, improve device effectiveness and reduce product recalls and modifications. Medical device users are an extremely heterogeneous group and for any one device the users may include patients and their carers as well as various healthcare professionals. There are a number of factors that make capturing user requirements for medical device development challenging including the ethical and research governance involved with studying users as well as the inevitable time and financial constraints. Most ergonomics research methods have been developed in response to such practical constraints and a number of these have potential for medical device development. Some are suitable for specific points in the device cycle such as contextual inquiry and ethnography. Others, such as usability tests and focus groups, may be used throughout development. When designing user research there are a number of factors that may affect the quality of data collected, including the sample of users studied, the use of proxies instead of real end-users and the context in which the research is performed. As different methods are effective in identifying different types of data, ideally more than one method should be used at each point in development. However, financial and time factors may often constrain this.

The right picture is worth a thousand numbers: data displays in anesthesia

OBJECTIVE

To review the literature on data displays in anesthesia identifying issues and developing design recommendations.

BACKGROUND

Unexpected incidents are common in critical care medicine. Adverse outcomes are frequently the catastrophic endpoints of an "evolving" chain of subtle incidents. One strategy to reduce the likelihood of an adverse patient outcome during anesthesia is to improve the anesthesiologist's ability to detect, diagnose, and treat critical incidents.

METHOD

A literature review and analysis of data displays.

RESULTS

Current numerical and waveform displays do not support anesthesiologists optimally. An alternative is graphical displays that functionally integrate variables into objects. In a well-designed graphic object, deviations from normal are shown by distortions in the object's symmetry. The emerging patterns that result from distorted symmetry facilitate the correct diagnosis. When treatment is effective, an object's shape is restored to normal. Graphical displays can be an effective tool in supporting anesthesiologists' situation awareness.

CONCLUSION

Problems related to graphical displays have delayed their use in anesthesia, including the lack of conclusive clinical evidence of their value. However, currently more evidence is accumulating that graphical displays have the potential to improve clinical performance. The successful development of these graphical displays takes into account task requirements, a user's perceptual processes, and task-specific cognition.

APPLICATION

This paper provides suggestions for the development of more effective displays in anesthesiology. Graphical displays can increase the anesthesiologist's situation awareness and improve clinical performance. Clinical use of these displays has the potential to significantly improve patient safety.

A baseline study of medication error rates at Baylor University Medical Center in preparation for implementation of a computerized physician order entry system

OBJECTIVE

To determine baseline levels of medication errors and their root causes so as to highlight areas of potential process improvements and serve as a ruler against which to measure future improvements.

DESIGN

A prospective pharmacist intervention study determining errors in 1014 medication orders at Baylor University Medical Center. Only errors in the process of medication ordering were documented; errors in drug administration were not considered. Root causes of errors were examined.

RESULTS

The baseline medication error rate was 111.4 per 1000 orders (n = 1014). Most common were dosing errors (43.4 per 1000 orders), followed by frequency errors (19.7 per 1000 orders) and unavailable drug errors (12.8 per 1000 orders). Of the 113 total errors found, 52 (46%) had a transcription-based cause, i.e., an error in inputting the handwritten physician order into a computer system. System- or process-related root causes (such as duplicate orders or lack of crossover from one information system to another) accounted for 35.4% of the errors, and prescribing based causes (such as wrong dosage or nonformulary drugs) accounted for 18.6% of errors.

CONCLUSIONS

Implementing a computerized physician order entry (CPOE) system would eliminate order-entry transcription-based errors. Its ability to resolve system/process-based and prescribing-based root causes of error is not as clear. Furthermore, the modification of processes due to implementation of CPOE could lead to new types of errors. Present processes must be redesigned according to evidence-based medicine, and future processes must be anticipated as technological changes occur. Such efforts-rather than outright reliance on technology--are more likely to lead to an error-free environment after CPOE is implemented.

Identification and characterization of errors and incidents in a medical intensive care unit

BACKGROUND

To assess the frequency, type, consequences, and associations of errors and incidents in a medical intensive care unit (ICU).

METHODS

Two-hundred and sixteen consecutive patients with predominantly cardiovascular and pulmonary disorders admitted between December 2002 and February 2003 were enrolled. Demographic data, SAPS II, and TISS-28 were obtained for all patients. Prior to patient enrolment all staff members (physicians, nurses, physiotherapists) were repeatedly encouraged to make use of the Incident Report Form (IRF) and detailed descriptions on how, why and when to use the IRF were provided.

RESULTS

During the observation period of 64 days, 50 errors involving 32 patients (15%) were reported. Patients subjected to errors were more severely ill (SAPS II 42 +/- 25 vs. 32 +/- 18, P < 0.05), had a higher hospital mortality (38% vs. 9%), and a longer ICU stay (11 +/- 18 vs. 3 +/- 5 days, P < 0.05). Gender, age and TISS-28 were equally distributed. Each day of ICU stay increased the risk by 8% (odds ratio 1.078, 95% confidence interval 1.034-1.125, P < 0.001), and by 2.3% per SAPS II point (odds ratio 1.023, 95% confidence interval 1.006-1.040, P < 0.001). The majority of errors and incidents were judged as 'human failures' (73%), and 46 errors and incidents (92%) as 'avoidable'.

CONCLUSIONS

The identification and characterization of errors and incidents combined with contextual information is feasible and may provide sufficient background information for areas of quality improvement. Areas with a high frequency of errors and incidents need to undergo process evaluation to avoid future occurrence.

Advanced patient monitoring displays: tools for continuous informing

We reviewed the use of advanced display technologies for monitoring in anesthesia. Researchers are investigating displays that integrate information and that, in some cases, also deliver the results continuously to the anesthesiologist. Integrated visual displays reveal higher-order properties of patient state and speed in responding to events, but their benefits under an intensely timeshared load is unknown. Head-mounted displays seem to shorten the time to respond to changes, but their impact on peripheral awareness and attention is unknown. Continuous auditory displays extending pulse oximetry seem to shorten response times and improve the ability to timeshare other tasks, but their integration into the already noisy operative environment still needs to be tested. We reviewed the advantages and disadvantages of the three approaches, drawing on findings from other fields, such as aviation, to suggest outcomes where there are still no results for the anesthesia context. Proving that advanced patient monitoring displays improve patient outcomes is difficult, and a more realistic goal is probably to prove that such displays lead to better situational awareness, earlier responding, and less workload, all of which keep anesthesia practice away from the outer boundaries of safe operation.

Measuring the performance of audible alarms for anaesthesia

The ergonomic performance of an integrated set of 17 audible alarm sounds, divided into low, medium and high priority classes has been undertaken. The sounds were tested for their ease of learning/recall, and how closely their intrinsic perceived urgency matched to a clinical assessment of urgency. The tests were computer-administered and performed on 21 volunteers aged from 18 to 52, in two sessions a few days apart. Session 1 taught the meanings of the alarm sounds and session 2 measured the performance of the sounds. The mean correct identification rate for the sounds was 48.4% (range 10.3-90.0%) with 97.5% of misidentifications within sound priority class. The urgency correlation was statistically significant (r=0.85, p<0.001) with all priority classes included but within priority class correlations were not statistically significant. Poor within priority class performances were ascribable to a priori aspects of the design of the sound system.

Anaesthetists' intentions to violate safety guidelines

The Theory of Planned Behaviour has been used to investigate the likelihood that anaesthetists will routinely perform three violations of safety guidelines. The three violations were: failing to visit patients before surgery, failure to perform pre-anaesthetic equipment checks and the silencing of alarms during anaesthesia. These suggested violations arose from discussions with the Medical Defence Union. In forming the intention not to perform these violations, anaesthetists are most influenced by their normative beliefs about the violation, i.e. the opinion they believe a group of peers and other significant other people would hold about them performing the violation. The next most influential factor is their personal norms, i.e. beliefs that the individual has about whether the violation is really right or wrong, followed by behavioural beliefs, i.e. beliefs about the consequences of performing the violation, and control beliefs, i.e. beliefs about how much control they have over performing the violation. The results show that the more intense the anaesthetists' belief that the violations were important, the less likely they were to violate, except for the case of alarm silencing. This result suggests that there may be a basic lack of confidence in the reliability of audible alarms that undermines their utility.