Work system design for patient safety: the SEIPS model

Detection and management of clinical deterioration in a virtual hospital: A work system analysis

Timely detection and management of patient deterioration is critical to minimise adverse events and death. The study aimed to understand the processes of detecting and managing deterioration in a virtual care environment, assess work system barriers and facilitators, and identify changes needed to the technology. Data were collected using interviews and document reviews and presented as process map and a work system analysis. We found that nurses and patients were key stakeholders in detecting deterioration, while management of deterioration was primarily performed by doctors and patients. We uncovered more barriers in the detection process than the management process, with the majority of barriers relating to technologies. Most facilitators related to people and included clinician expertise and carer support. Duplication of work and difficulty assessing some signs virtually were also revealed as barriers to the deterioration detection process. This study led to work system changes to mitigate some of these barriers.

Development and Evaluation of a Multifaceted Intervention Program for Preventing Medication Administration Errors by Nurses

OBJECTIVE

This study aimed to develop and evaluate a multifaceted intervention program based on the Systems Engineering Initiatives for Patient Safety (SEIPS) model to prevent medication administration errors (MAEs) by nurses in an adult general ward of a comprehensive hospital in Seoul, South Korea.

METHODS

The program was developed using the Analysis, Design, Development, Implementation, Evaluation (ADDIE) model with a 3-round Delphi survey conducted with 16 experts. Strategies were categorized under the SEIPS model and finalized into a program with 9 domains and 21 interventions. A pretest-posttest design with 73 nurses (36 experimental, 37 control) evaluated the program's effectiveness in a tertiary care hospital in Seoul, South Korea. Surveys on patient safety culture, medication safety practices, and error rates were analyzed before and after a 3-month intervention using double-difference and time-series methods.

RESULTS

The DID analysis demonstrated significant improvements in patient safety culture perception (0.42, P <0.001) and medication safety compliance (0.53, P <0.001), with large effect sizes ( d =1.07 and d =1.41, respectively). However, changes in self-reported medication error rates between groups were not statistically significant ( P =0.555), likely due to the short intervention period.

CONCLUSION

The program improved patient safety awareness and medication safety compliance, validating its approach. This study highlights the importance of theoretically based interventions and suggests shifting from solely nurse education to addressing systemic issues for medication safety.

The scope of emergency nursing viewed through the lens of complex adaptive systems: A discussion paper

Across the world, emergency department nurses care for patients around the clock all year long. They perform tasks ranging from direct nursing care to managing patient flow, working in an environment characterised by interdependencies among numerous actors. The complex context in which emergency nurses operate has not been thoroughly described or discussed, indicating a knowledge gap. Hence, the aim of this discussion paper is to describe and discuss nursing in the emergency department and the connection between patient flow and nursing care, drawing on the concept of complex adaptive systems. The acts of direct patient care and patient flow, when viewed through the lens of complex adaptive systems, are central components of emergency nursing. Through a stepwise description of these two perspectives, based on literature and clinical experience from European countries, the paper illustrates the complexity of the emergency nursing context in a novel manner. We argue that direct patient care and patient flow, combined as patient flow management, constitute essential parts of the core of emergency department nursing. Further studies are needed to challenge or confirm this assertion.

Modeling anesthesia medication delivery using the SEIPS 101 tools

BACKGROUND

Reducing the risk of patient harm during anesthesia medication administration in perioperative settings has been a long-term goal in patient safety. SEIPS 101 tools, provide a series of practice-orientated techniques to apply systems model in real clinical practice, potentially offering a straightforward approach to mapping perioperative medication delivery systems. Data was collected during direct observations of thirty-eight anesthetics, totaling over 100 h on anesthesia providers' common tasks and interactions with people, environments, tools, and technologies. Observation data, notes, interviews, and literature were organized to create six SEIPS 101 tools demonstrating the complexity of anesthesia medication delivery. The Anesthesia PETT Scan represents the facilitators and barriers associated with differences in individual expertise, preferences, and potential conflict between providers. The People Map demonstrates the wide range of relevant individuals in medication delivery. The Task x Tools Matrix depicts the broad range of interconnected processes to provide anesthesia. The Journey Map describes the path used to deliver a medication. The Anesthesia Work System Interactions Map identifies necessary interactions that providers have with tools, tasks, people, and environment for successful anesthetics. The Outcome Matrix describes various stakeholder experiences and outcomes that contribute to overall system complexity. Identifying and describing the complexity in the anesthesia care delivery system is critical for effective and efficient process-centric interventions. This systems analysis may increase awareness to the limitations of current approaches and improve upon methods and interventions for understanding errors, safety, and the nature of clinical expertise and decision making.

Treatment Acceptability and Satisfaction With Cough Skill Training in Parkinson's Disease: A Mixed-Methods Study

PURPOSE

Despite evidence to suggest that rehabilitation can improve airway protection in people with Parkinson's disease (pwPD), rehabilitative therapies are underutilized. One newer treatment approach with growing evidence to support its efficacy is cough skill training (CST). To improve utilization of rehabilitations such as CST, it is important to understand patient treatment experience. Therefore, the aim of this study was to define treatment acceptability and satisfaction of CST in pwPD.

METHOD

Thirteen pwPD were consecutively recruited from a trial during which participants completed two in-person sessions of CST via spirometry over 2 weeks. A mixed-methods approach was used, whereby quantitative data (obtained from questionnaires) and qualitative data (obtained from semistructured interviews) were integrated to provide a holistic understanding of patient experience. Data collection and thematic analyses (of qualitative data) were guided by the Systems Engineering Initiative for Patient Safety framework.

RESULTS

While treatment demonstrated adequate acceptability with a System Usability Scale median score of 70/100 (scores ≥ 70 indicate acceptability), integrative examination of patient experience revealed several themes that highlight barriers and facilitators to treatment acceptability-as they relate to CST tools (visualization, lip seal, and measurement accuracy) and tasks (practice targets, feedback, practice amount, and future training). Most (61.5%) participants were "satisfied" or "very satisfied" with CST. Four themes emerged related to satisfaction: treatment relevance, patient awareness and control over their disease, skill acquisition, and skill transference to real-life choking events.

CONCLUSIONS

In this study, patient responses indicated that small, personalized adaptations to equipment, training targets, and feedback may enhance their experiences, while education and personalized goal setting may enhance treatment relevance and perceived benefit. Patient perspectives and needs can inform the refinement of person-centered clinical implementation of CST and improve treatment uptake.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28887167.

Perspectives on Airway Protection: A Mixed Methods Investigation in People With Parkinson's Disease

PURPOSE

Disordered airway protection, including both disordered swallowing (dysphagia) and disordered cough (dystussia), is highly prevalent among persons with Parkinson's disease (pwPD). A comprehensive understanding of the perspectives of pwPD as it relates to airway protection is currently lacking and is necessary to provide relevant, person-centered care. Therefore, this study used a parallel-convergent mixed methods design to quantitatively and qualitatively investigate pwPD's perspectives on airway protection.

METHOD

Thirteen pwPD were consecutively recruited from a cough training trial. Quantitative data (obtained from the Swallowing Quality of Life questionnaire [SWAL-QOL] and the modified Canadian Occupational Performance Measure [mCOPM]) and qualitative data (obtained from semistructured interviews) were integrated to define participant knowledge, perceived importance, perceived performance, and psychosocial implications of airway protective deficits.

RESULTS

All participants reported basic knowledge about airway protection, which centered around four themes-physiology, the interconnectedness between bulbar functions, danger, and impaired airway protection as a consequence of PD. All participants believed that airway protection was important (median mCOPM score = 10), with three primary themes related to importance-survival, anticipated future decline, and maintaining oral intake. We identified a split between participants who perceived themselves to have "a swallowing problem" and those who did not, with three themes relating to perceived impairment-use of eating strategies, unpredictable and inconsistent symptom experience, and vigilance required to mitigate symptoms. Psychosocial ramifications centered on three key themes that aligned with three SWAL-QOL domains-overall burden, fear of future decline, and social embarrassment.

CONCLUSION

The integration of quantitative and qualitative data in this study highlights the importance of considering unique patient perspectives to develop personalized and relevant management plans for each unique pwPD that integrate objective and clinical findings with patient priorities and needs.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28489280.

Exploring the complexity of safe insulin management during transfer of care using qualitative methods

AIMS

Managing insulin during care transfers requires improvement. Understanding factors that impact insulin management during this process improves the likely effectiveness of interventions. This study aimed to map the processes involved in managing insulin during transfers of care and the factors that affect them to identify potential areas for safety improvement interventions.

METHODS

A qualitative, case study approach was used to undertake documentary analysis, interviews, focus groups and observation. Participants included people with diabetes who use insulin, caregivers and primary and secondary care healthcare professionals. A framework approach guided analysis and subtheme categorisation under the domains of people, tools, tasks or environments.

RESULTS

Insulin management during transfers of care was mapped across hospital admission and discharge along with factors that impact this process. Six stages of the care transfer process were identified. Workforce pressures and demand impacted safe insulin management. Four themes were identified: (1) People with diabetes hold vital information not otherwise available, (2) their ability to manage their diabetes care in hospital was limited, (3) healthcare staff lacked confidence managing insulin and (4) people anticipated and acted to prevent known issues.

CONCLUSIONS

A detailed picture of factors impacting insulin management during the transfer of care was developed. Incorporating the expertise of people who use insulin and removing barriers to insulin self management across the care pathway, ensuring staff have adequate knowledge, skills and confidence in the management of insulin and promoting proactive interventions to support safe outcomes represent key interventions to improve safety for people who use insulin.

Mixed Methods Study of the Interfacility Transfer System Utilizing Both Patient-Reported Experiences and Direct Observation of the Transfer Consent Process

BACKGROUND

Interfacility transfer is an integral component of the modern health care system. However, there are no commonly agreed-upon standards for interfacility processes or for patient engagement and shared decision-making in transfer, and little is known about their experience. This study used qualitative methods to better understand the patient and care partner experience with interfacility emergency department (ED)-to-ED transfer.

METHODS

This mixed methods study used two distinct data sources: (1) semistructured interviews of older adult patients and their care partners, performed at bedside in a large, tertiary care hospital (receiving facility) following interfacility transfer, and (2) direct observation of the transfer consent process at two community EDs (referring facilities) in the same health system.

RESULTS

A total of 21 patients and 14 care partners were interviewed. The authors identified several common themes related to perceptions and experiences with interfacility transfer: (1) communication (for example, perceived lack of agency), (2) logistics (for example, wait times), (3) impacts on family (for example, distance from home), (4) uncertainty about the bill (for example, transfer-associated costs), and (5) quality of care (for example, greater trust in tertiary care centers). Direct observations of the transfer consent process for 14 unique patient encounters were also conducted. The research team observed considerable variability in practice patterns among sending clinicians and identified frequent patient-reported issues related to transfer logistics and effective communication, including distractions, lack of privacy, absence of support system, physical pain and/or psychological stress, preferred language, and health literacy.

CONCLUSION

These data suggest several potential areas for improvement in the care of patients requiring interfacility transfer, to increase engagement and allow patients and their care partners to make better-informed decisions most consistent with their goals of care.

Identifying resilience: a system safety review of trauma and orthopaedic theatres

A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding 'work as done' to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.

A Qualitative Study of Factors That Influence Older Adults' Work on the Arduous Path to Spine Surgery

Background and Aims

Older adults worldwide are increasingly diagnosed with degenerative spine disease (DSD). Although older adults are frequently interacting with the healthcare system, clinicians are likely not aware of the many health-related activities, or patient work that older adults engage in to achieve their health goals. An understanding of patient work is needed to guide patient-oriented healthcare improvements for older people having surgery for DSD to achieve their desired health outcome. Our aim was to define factors in the patient work system that influence the patient work of older adults in the preoperative phase of spine surgery.

Methods

Secondary analysis of data (28 interviews) from older adults who underwent spine surgery, using deductive and inductive qualitative content analysis to describe patient work system factors. Components from the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 human factors ergonomics framework (person, organization, task, internal and external environments, tools/technology) guided 2-member independent coding, codebook evolution, and team analysis.

Results

We identified 16 patient work system factors that influenced older adults' patient work during the preoperative time before spine surgery. The primary work system influencers included: severely limited physical function; inability to socialize; multiple providers and appointments; self-management knowledge; emotions and mental state; active decision making; explaining treatment options; inability to complete household chores and self-care; physical and emotional care and monitoring (by family); family coordinating care; household duties relinquished; complex scheduling of healthcare; home layout; insurance requirements; waiting for care; and devices to manage symptoms (medications; mobility hardware).

Conclusions

Factors that influence patient work are often a result of debilitating symptoms causing loss of independence, isolation, and confusion of how to meet their health goals. The influencing factors warrant research and process improvement initiatives. Thus, lessening the patient work burden and improving health outcomes.

A balanced approach to using organizational patient safety incident data for research

Reported patient safety incidents offer high-value perspectives on safety threats but can be an untapped source of learning due to their sensitive nature and the presence of potential data protected under Quality Assurance (QA) legislations. There are no published guidelines for leaders to enable ethical use of data protected under QA legislation in reported patient safety incidents within the Canadian context. Liberating this data requires understanding the appropriate purposes for use, which draws on ethical and privacy-related considerations. We describe the approach followed to balance the duty to protect relevant privacy interests with the moral obligation to conduct research, and the proactive prevention of patient harm at our Canadian multi-site academic health sciences centre. Overall, we developed guidelines and discovered leaders must commit to establishing connections between organizational governance, legal structures, and privacy experts to support research enabling learning from patient safety incidents.

Identification and classification of risk factors for mental health problems in healthcare workers using a systemic framework: an umbrella review

BACKGROUND

Mental health problems are high among healthcare workers (HCWs) due to difficult and complex working conditions. This study aims to investigate the prevalence of depression and anxiety through existing meta-analyses and identify risk factors related to these mental health issues at different levels of the work system.

METHODS

We conducted an umbrella review with a scoping approach to identify and select studies related to depression and anxiety among HCWs. This study was conducted according to a five-step scoping approach. The search included only studies published before January 2024. The final studies were reviewed and selected using EndNote X9, with information extracted according to specific criteria.

RESULTS

Sixty-one studies were included in the final stage and necessary information was extracted from them, 47 articles reported prevalence and risk factors were extracted from 29 articles. Most of the studies were conducted in the context of Covid-19. prevalence of depression varied between 20.5% and 46.2% and for anxiety, it was between 21.9 and 47%. Factors related to depression and anxiety were divided into four levels of the work system, including individual factors, work and unit factors, organizational factors, and external factors.

CONCLUSIONS

Numerous secondary studies indicate a high prevalence of depression and anxiety among HCWs, especially during the COVID-19 pandemic. This study introduces a framework for systematically identifying mental health problems. Future research is encouraged to utilize this framework to identify risk factors contributing to mental health challenges. It is recommended to use a systemic approach to managing mental health problems.

Using network analysis to support fluid teams managing postpartum hemorrhage

Traditional approaches to improve teamwork during postpartum hemorrhage (PPH) may not be effective for dynamic situations with fluid team members. In this study, we use the Systems Engineering Initiative for Patient Safety (SEIPS) model as a framework to identify strategies to improve the teamwork of fluid teams managing PPH. We administered a close-ended survey to explore how clinicians in the obstetrics and gynecology department perceive their team membership, team interactions, and team effectiveness when managing PPH. Then, we used network analysis to understand how clinician interactions differ and describe the relationship between team membership and team effectiveness. Our results showed that the type and frequency of interactions differed between the participant roles. Additionally, our results showed a weak, positive correlation between team membership and effectiveness. From our findings, we identified two work system design strategies to improve teamwork: establish a decentralized communication structure and implement task-focused behaviors.

Threats to performing high-risk resident care activities in nursing homes: A work system analysis

Infections from multidrug-resistant organisms (MDROs) are a major concern for nursing home (NH) resident morbidity and mortality. Our goal was to identify threats to healthcare workers (HCWs) safely and efficiently performing resident care activities that contribute to MDRO transmission in NHs. Following focus group discussions with certified nursing assistants, we identified threats in terms of the Systems Engineering Initiative for Patient Safety work system model and then induced 24 broader themes. We then used Fuzzy Cognitive Mapping (FCM) to characterize how themes influence one another. FCM revealed two prominent themes that increase the amount of physical contact (transmission) between HCWs and residents and promote lapses in preventative practices during high-risk activities: 1) additional steps or tasks arising during these activities and 2) when these activities become otherwise prolonged. These themes were driven by themes related to the organization, residents, and residents' caregivers. To reduce MDRO transmission from these activities, the work systems of NHs must better support the capabilities, limitations, needs, and preferences of both the HCWs providing and the residents receiving care.

The impact of psychological factors on interprofessional team collaboration in the ICU: A macro-ergonomic case study

This cross-sectional study investigates the influence of mental well-being and conflict recognition on a team performance-related measure, interprofessional collaborative practice, of medical residents in the intensive care unit. Utilizing a sample of 44 residents from diverse demographics, we analyzed the descriptive statistics and linear regression coefficients. Results reveal significant relationships between baseline stress and anxiety levels on individual performance, with higher baseline stress correlating with decreased performance across interprofessional collaborative practice, while higher anxiety levels were associated with improved interprofessional collaborative practice. Furthermore, conflict awareness emerged as a determinant of interprofessional collaborative practice. These findings underscore the importance of addressing personal traits and psychological health factors in optimizing team performance within ICU settings, one of the primary goals of macro-ergonomics. Implementing strategies for improving interprofessional collaboration is essential for establishing a shared understanding of optimal critical care practices and effective teamwork and communication.

Assessing Radiology Workflow Interruptions in the Era of Electronic Communications: A Human Factors Engineering Approach

RATIONALE AND OBJECTIVES

To identify the frequency and nature of messages, communication topics, and the contextual factors that lead to communication and potentially detrimental workflow interruptions via an electronic communication platform (ECP; WebEx) in a multi-subspecialty academic radiology practice.

MATERIALS AND METHODS

In this retrospective sequential mixed methods quality improvement study, we performed quantitative analysis of WebEx messages from July 2022 to July 2023. Message frequency was determined across three daily timeframes corresponding to radiology coverage shifts. Structural topic modeling (STM) was used to identify common communication topics in WebEx. Semi-structured interviews with technologists and residents were performed to determine the context behind these topics. The Systems Engineering Initiative for Patient Safety (SEIPS) framework was used to analyze contextual factors influencing communication.

RESULTS

A total of 39,448 WebEx messages were analyzed. Timeframes with the highest frequency of messages were 7:30 AM-4:30 PM (4.2 messages/hr [SD 3.4]) and 4:30 PM-9:00 PM (4.2 messages/hr [SD 3.5]). Protocol-related questions were the most frequent topic (13%), followed by clarifications regarding allergy and contrast (7%), and exam appropriateness. 24 contextual factors influencing communication via WebEx were identified, including organizational factors (e.g., psychological safety, perceived workload), task characteristics (e.g., protocol complexity, time pressure), person characteristics (e.g., experience of technologists and residents), and physical environment (e.g., noise).

CONCLUSION

High electronic message volumes and unnecessary interruptions via low friction ECPs and ad hoc messaging negatively impact radiology workflows and could affect patient safety. Organizational communication protocols could reduce workflow disruption for radiologists and technologists. Optimizing ECP communication protocols by time of day and message type could also improve workflow efficiency, ultimately enhancing patient safety and productivity. Future implementation of targeted interventions using these data is warranted.

SUMMARY

Human factors engineering strategies show that interruptions from high volume electronic communications that potentially have a negative impact on workflow, workload, and patient safety are contextual in nature. This study identifies targets for improved electronic communications in a busy academic radiology practice.

Designing better systems to navigate the sepsis-antimicrobial stewardship tension

Sepsis is a leading cause of preventable death and requires timely antimicrobial treatment to reduce mortality. Despite extensive sepsis management guidelines, high-income countries continue to have considerable rates of sepsis mortality, indicating a gap between guideline quality, usability, and practical application. Simultaneously, the rise of antimicrobial resistance threatens the efficacy of antimicrobial therapies for infection control, underscoring the tension between sepsis management and antimicrobial stewardship. This Personal View explores how system factors, such as people, environments, tools, technologies, and tasks, influence the sepsis-antimicrobial stewardship tension. With the Systems Engineering Initiative for Patient Safety, we use a case study to highlight how organisational pressures, inadequate diagnostic tools, and sociocultural factors drive the gap between work-as-imagined and work-as-done. These latent safety risks that impede guideline adherence and contribute to unintended antimicrobial use highlight the need to design better systems, not blame individuals for non-compliance. We argue that addressing sepsis and antimicrobial resistance requires a holistic systems approach and that every discipline, including policy makers, clinicians, researchers, and drug developers, should adopt systems thinking in the design of interventions intended to address this problem. This shift is essential to ensuring effective care for patients today while safeguarding the effectiveness of antimicrobials tomorrow.

A framework for patient access management: consensus from a Delphi panel of US health system leaders

BACKGROUND

Patient access management in the ambulatory setting is important for health systems as waits and delays lead to reduced health outcomes, inequity, and poor patient experience. Health systems may benefit from a framework that catalogs the determinants of access management in the ambulatory setting to deliver timely care to all patients.

METHODS

The aim of this research is to define patient access and document the determinants of patient access management through a consensus from a two-stage Delphi panel of access leaders in US academic health systems and children's hospitals.

RESULTS

The study demonstrates a patient-centered definition of patient access management focusing on the delivery of timely, simple, connected access to care. Twelve major determinants were identified for patient access management: executive leadership support, dedicated access leadership, system strategy prioritization, data collection and analysis, contact center management, capacity management, appointment availability, appointment accuracy, measurable and defined goals, simplification of system for patients, timely offering of care, and patient-clinician connection. The determinants were applied to a framework using the Donabedian model. Frameworks may improve validity and reliability in performance improvement activities.

CONCLUSIONS

Health systems may benefit from prescriptive strategies to identify, diagnose, resource, and address the determinants that constitute patient access management. Additional research is warranted to understand each determinant.

The work system of prehospital medication administration: a qualitative mixed methods study with ambulance professionals

BACKGROUND

The characteristics of medication administration within the prehospital setting are underexplored. Ambulance professionals operate under varied levels of responsibility, dependent on their training and collaboration with local emergency facilities and other medical personnel. Given the critical condition of many patients using these services and the challenging environments they operate in, the risk of adverse drug events is significant. The aim was to advance the knowledge of the medication administration process in the setting of ambulance services.

METHODS

A qualitative mixed-methods design was applied to examine the medication administration process among ambulance professionals in a Norwegian hospital trust. Data collection included individual semi-structured interviews with 11 ambulance professionals at three ambulance stations, complemented by 114 h of observations. Interviews and observations were guided by the System Engineering Initiative for Patient Safety (SEIPS) work system model, and data were analyzed using a combined deductive-inductive content analysis.

RESULTS

The medication administration process in the ambulance work system is condensed into three stages: preparation, administration, and patient transfer, primarily due to constraints related to time and available information. The medication administration work system is influenced by a set of eight interrelated categories. These include technological aspects such as workarounds necessitated by inadequate equipment, organizational dynamics such as the fluid delegation of tasks, physical environmental conditions that impact on decision-making, and personal factors such as collaboration in managing critical patient scenarios.

CONCLUSION

Medication administration tasks in the ambulance service take place along a continuum involving physical, technological, and organizational factors that interact and continuously influence ambulance professionals in their everyday practices. The study highlights the need for enhanced medication administration processes in ambulance services through improved collaboration, training, technological usability, and organizational adaptability.

Training Hospital Nurses to Write Detailed Narratives and Describe Contributing Factors in Incident Reports: The SAFER Education Program

BACKGROUND

In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety.

METHODS

The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center.

RESULTS

An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy-a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses).

CONCLUSION

SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.

Exploring Willingness to Use Long-Acting Injectable PrEP Among Sexual and Gender Minoritized People Accessing Pharmacies

This mixed-methods study explored willingness to use long-acting injectable pre-exposure prophylaxis (LAI-PrEP) among a pharmacy-based sample of men, including sexual and gender minoritized (SGM) individuals. We conducted qualitative interviews (n = 10) with HIV-negative Black men, including Black SGM individuals, and surveys (n = 103) across three study phases with men recruited from community pharmacies in Atlanta, Georgia. Interviews explored perceived benefits and concerns related to LAI-PrEP; surveys assessed willingness and related reasons. Thematic analysis was used for interview transcripts, and descriptive statistics summarized survey responses. Participants mentioned benefits such as improved adherence and reduced stigma, but also noted concerns about medical mistrust and fear of needles. Willingness was higher in the transitional pilot phase than in the pilot phase, where concerns about side effects and comfort were more common. Findings highlight the need for tailored LAI-PrEP strategies that address barriers among Black SGM populations and promote equitable HIV prevention.

A conceptual framework for identifying and managing system vulnerabilities for diversion of controlled substances in healthcare

PURPOSE

Diversion or theft of controlled substances is a recognized problem affecting healthcare systems globally. The purpose of this study was to develop a framework for identifying and characterizing system factors leading to vulnerabilities for diversion within hospitals.

METHODS

We applied a qualitative framework method, which involved 1) compiling a list of critical diversion vulnerabilities through observations and proactive risk analyses in the inpatient pharmacy, emergency department and intensive care unit of two Canadian hospitals; 2) coding the vulnerabilities into deductively and inductively derived themes and subthemes; and 3) building a conceptual framework.

RESULTS

Our framework for diversion demonstrates how mitigating downstream diversion outcomes (e.g., harms to patients, healthcare workers, and institutions) requires the redesign of upstream system factors associated with pilfering and forgery processes. We identified 20 subthemes associated with the following five overarching themes of system factors contributing to diversion risk: task (e.g., variation in how work was done or lack of verification), person (e.g., use of insider knowledge or collaboration among staff), tools/technologies (e.g., limitations of electronic systems to identify discrepancies), organization (e.g., cultural/behavioural norms or hospital policies for controlled substance management), and internal environment (e.g., layout of the space).

CONCLUSION

The Diversion Framework is a conceptual model developed for use by practitioners, researchers, and policy makers to identify system factors and analyze medication-use processes that may be vulnerable to diversion. This in turn can inform safeguards to prevent harm to patients, healthcare workers and the institution.

The Singapore Green Plan 2030: occupational health hazards in the Singapore green economy

ABSTRACT

The Singapore Green Plan 2030 was released by the Singapore government to set targets for sustainability by 2030. The adoption of novel technologies, processes and substances creates new jobs, and such developments bring about new challenges and risks for both employers and workers. Beyond emerging hazards, traditional hazards still remain, but they may take on new forms through new work processes. This review aims to provide an overview of the potential occupational health issues we may encounter or anticipate in these key sectors: solar energy, waste management and recycling, green buildings, electric vehicles and battery recycling, and sustainable fuels. While existing Occupational Safety and Health regulations in Singapore serve as a foundation, there may be gaps in addressing the specific hazards and risks associated with green jobs. In this review, we propose and outline possible approaches to the protection of worker safety and health.

Safety Interventions in Cardiac Anesthesia: A Systematic Review

BACKGROUND

The cardiac operating room is a complex, high-risk, sociotechnical system. Risks in cardiac surgery and anesthesiology have been extensively categorized, but less is known about effective risk reduction strategies. A comprehensive understanding of effective, evidence-based risk reduction strategies is necessary to improve patient safety in cardiac anesthesia.

METHODS

An advanced literature search of MEDLINE, CINAHL, Embase, and Web of Science databases was conducted to identify studies involving the introduction of a tool or intervention to improve patient safety and human factors in cardiac anesthesia. Studies were screened independently by two authors applying prespecified inclusion and exclusion criteria. Risk reduction strategies and safety initiatives identified were classified according to the Systems Engineering Initiative for Patient Safety model. Data were extracted using a standardized form and were narratively synthesized.

RESULTS

A total of 18 studies were identified for inclusion using preoperative briefing tools, intraoperative checklists, and postoperative handover tools. Preoperative briefing tools were associated with a significant reduction in patient mortality and length of hospital stay and also led to adaptations to planned operation. Intraoperative checklists demonstrated decreased bleeding, mortality, and blood transfusion requirements. Postoperative handover tools were associated with improved information transfer and teamwork.

CONCLUSION

This review identified three categories of tools that may be used to improve patient and organizational outcomes. Many of these tools are simple to introduce and sustainable in the long term and can be readily adapted to different centers.

Internal Medicine Resident Perceptions of the Barriers to and Facilitators of Optimal Inpatient Care for HIV Prevention of Persons Who Inject Drugs: A Mixed Methods Study

Hospitalizations are an opportunity to offer HIV prevention services to persons who inject drugs. We used mixed methods to describe barriers and facilitators perceived by internal medicine residents to providing these services. Education and electronic medical record interventions can assist our residents in providing this care inpatient.

The Impact of the Burden of COVID-19 Regulatory Reporting in a Small Independent Hospital and a Large Network Hospital: Comparative Mixed Methods Study

BACKGROUND

During the COVID-19 pandemic in 2020, hospitals encountered numerous challenges that compounded their difficulties. Some of these challenges directly impacted patient care, such as the need to expand capacities, adjust services, and use new knowledge to save lives in an ever-evolving situation. In addition, hospitals faced regulatory challenges.

OBJECTIVE

This paper presents the findings of a qualitative study that aimed to compare the effects of reporting requirements on a small independent hospital and a large network hospital during the COVID-19 pandemic.

METHODS

We used both quantitative and qualitative analyses and conducted 51 interviews, which were thematically analyzed. We quantified the changes in regulatory reporting requirements during the first 14 months of the pandemic.

RESULTS

Reporting requirements placed a substantial time burden on key clinical personnel at the small independent hospital, consequently reducing the time available for patient care. Conversely, the large network hospital had dedicated nonclinical staff responsible for reporting duties, and their robust health information system facilitated this work.

CONCLUSIONS

The discrepancy in health IT capabilities suggests that there may be significant institutional inequities affecting smaller hospitals' ability to respond to a pandemic and adequately support public health efforts. Electronic certification guidelines are essential to addressing the substantial equity issues. We discuss in detail the health care policy implications of these findings.

Mapping the patient journey: Understanding oral anticancer medication use among patients diagnosed with breast cancer

IntroductionA growing number of patients with breast cancer use oral anticancer medications (OAMs) but may face barriers in managing their therapy at home, potentially impacting their treatment outcomes. Understanding these barriers is essential to designing effective interventions. This study aimed to identify unmet medication management needs of patients with breast cancer receiving OAMs.MethodsQualitative semi-structured interviews were conducted to create patient-specific journey maps describing OAM use. Participants were recruited from a federally qualified health center's breast cancer clinic in central Indiana. Eligible patients were 18 years of age or older, diagnosed with breast cancer, and currently receiving OAMs. Participants completed a sociodemographic survey, and researchers and participants collaborated to create visual storyboards of medication use experiences, highlighting timelines, key markers, and barriers. Journey maps were consolidated, and personas were created to represent patients with similar characteristics. Participants were categorized by medication type: specialty (requiring specialty pharmacies) or traditional (available at community pharmacies).ResultsTwelve participants (11 females, 1 male; median age 65.5 years, range 37-75) were interviewed. Four were receiving specialty medications (palbociclib, ribociclib), and eight were receiving traditional medications (tamoxifen, anastrozole, exemestane). Two personas were created. The specialty medication group reported difficulties navigating the insurance system, whereas the traditional group did not. All participants experienced side effects, and sub-optimal adherence (n = 2) was reported only in the traditional group.ConclusionThis study provides insights into the patient experience with OAMs. Personas and journey maps can guide the development of tailored interventions to improve treatment outcomes.

Huddles in Hospital Maternity Settings: A Scoping Review

BACKGROUND

The Agency for Healthcare Research and Quality recommends the use of safety huddles, in which clinicians are briefly gathered to review a patient's condition, including new or developing changes in acuity or stability. The Joint Commission describes huddles as a "hallmark" of high-reliability organizations. Previous reviews have confirmed the general utility of huddles, including positive regard by clinicians, but there has not been work specifically looking at huddle use in hospital maternity care settings. Our objective was to identify the ways that huddles have been studied or reported in inpatient maternity settings and synthesize this information with recommendations from professional organizations to identify gaps in the literature published in the United States since 1999.

METHODS

We used Arksey and O'Malley's framework to guide our scoping review. Using the time frame from 1999 to 2024, we searched the following databases: PubMed, CINAHL, SCOPUS, Embase, as well as gray literature and the reference lists and citing articles of the included manuscripts.

RESULTS

We found 160 documents, of which 47 met inclusion criteria, including 11 care bundles, 10 quality improvement projects, and 4 research studies. The remaining 22 were a variety of editorials, position papers, and other gray literature.

DISCUSSION

There is scant research on the use of huddles in hospital maternity care settings, and most literature does not define the participants, timing, or agenda of the huddle. Further research is needed to understand how huddles affect outcomes in maternity settings. Researchers should explicitly define the huddles they are studying. The review protocol was registered at Open Science Framework Registries.

Improving Medication-Related Safety for Residents in Nursing Homes: A Qualitative Study

PURPOSE

To gain a better understanding of the perceptions of RNs on medication safety concerns and potential solutions for nursing home (NH) residents.

METHOD

This prospective, qualitative study used semi-structured phone interviews with a description approach. We used purposeful sampling to recruit 12 RNs employed at two NHs in the northeastern region of the United States. The Systems Engineering Initiative for Patient Safety constructs informed the interview guide, coding, and qualitative theme identification.

RESULTS

We categorized non-user-friendly charting systems and gained insights into more experience with paper-based charting under the technology component. For the organization component, participants identified the importance of teamwork, communication, and leadership. Participants also mentioned how education and nationality of training impact medication administration (MA) safety. Task-related concerns revealed how different care approaches, extreme workload variation, and task prioritization during the day are perceived as critical issues that need to be addressed. Staff shortages were also expressed as an environment-related concern.

CONCLUSION

Findings highlight the importance of appropriate nurse-to-patient ratio, the significance of user-friendly charting systems, and customizing the interface of MA in the charting system. [Journal of Gerontological Nursing, 51(3), 38-43.].

Time constraints and workload in the computed tomography department

INTRODUCTION

The escalating use of Computed Tomography (CT) has promoted higher radiographer workload, which can contribute to an increase of risks such as stress, job dissatisfaction, and potential health and safety issues. This study aimed to assess the impact of organizational, spatial, and temporal factors on procedures and workload in a CT unit, emphasizing patient safety and radiographer well-being. Addressing time pressure and optimizing workplace ergonomics are crucial in maintaining a balance between efficiency and quality, ensuring safe practices in modern medical imaging units.

METHODS

The study was conducted in a Swiss university hospital CT unit and employed the Systems Engineering Initiative for Patient Safety (SEIPS) model to analyse the radiographers' workflow and time constrains. Observations and tasks' analysis were used to collect data, including timing and location of tasks performed by radiographers.

RESULTS

The radiographers' workflow in the CT department is complex, involving multiple tasks. The entire process spans from 26 to 41 min but the Machine-Time (time spent inside the CT room) ranged from 10 to 16 min. The study identified inefficiencies in the workflow, namely in time spent on patient preparation and unsuited machine-time rate. The layout of the department, including limited space in the preparation area, contributing to ergonomic challenges for radiographers. Organizational factors, such as scheduling practices, also impacted workflow. The examination durations varied by type of scan and patient, leading to time pressure and potential safety concerns.

CONCLUSIONS

The study highlighted the need for more realistic time allocation in CT examinations to improve patient and radiographer safety. Recommendations include extending machine-time rate, adapting examination durations based on the type of CT, and assigning a dedicated radiographer for order review. It is also crucial improving the working environment to accommodate ergonomic needs. Addressing these issues can enhance the efficiency and safety of CT departments, benefiting both patients and radiographers.

IMPLICATIONS FOR PRACTICE

Healthcare organizations should consider these study recommendations to improve the efficiency and safety of CT departments. By implementing the recommended changes, such as adjusting CT-time rate and optimizing working environments, radiographer satisfaction and patient safety can be increased, ultimately leading to safer and more effective CT services.

Understanding and mapping the antibiotic prescribing and administration process in assisted living facilities

Objective

Inappropriate prescribing practices significantly contribute to antibiotic resistance which poses a significant public health challenge. While antibiotic prescribing and administration process has been widely studied in various settings including nursing homes, little is known about Assisted Living Facilities (ALFs). This study aims to map the antibiotic prescribing and administration processes in ALFs.

Design

A qualitative descriptive study using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model.

Methods

Seven semi-structured interviews were conducted with staff from five ALFs located in a mid-western state. Participating staff were either involved in or knowledgeable about the process. The interviews were analyzed in NVivo using SEIPS 2.0 model as a theoretical framework.

Results

The analysis informed the mapping of a 33-step antibiotic prescribing and administration process for residents in ALFs. They were grouped into five sections: admission, resident having a change in condition, antibiotic prescribing, obtaining the prescription from the pharmacy, and antibiotic administration and follow-up. Pharmacies played critical role in delivery of prescriptions to ALFs and are uniquely positioned to support antibiotic stewardship efforts.

Conclusions and implications

This study is among the first to systematically map the antibiotic prescribing and administration process in ALFs. Insights gathered regarding the use of preferred pharmacies highlight opportunities for pharmacists in stewardship practices. Comparison of the process to that of nursing homes, suggests that several pharmacist-led stewardship interventions used there could be adapted effectively in ALFs. Further research is essential to assess the impact of antibiotic prescribing and pharmacist-driven stewardship interventions tailored specifically for ALFs.

Maximizing Surgical Success by Aligning Interventions to Outcomes: A Systematic Review

Objective

This study aimed to identify common intraoperative interventions in surgery and evaluate their effectiveness in improving surgical outcomes.

Background

Despite decades of efforts, surgical adverse events remain stubbornly high. There are concerns that too much responsibility is placed on individuals to create change (ie, person-based interventions) rather than adapting systems to support human performance (ie, system-based interventions). This focus may be due to our limited understanding of which interventions most effectively improve outcomes.

Methods

A 2-step search was conducted. Systematic and meta-analytic reviews of Medline, CINAHL, Embase, PsycINFO, Scopus, Cochrane Reviews, Cochrane Protocols and Cochrane Trials were identified, and individual studies within these reviews were selected. Qualitative content analysis categorized intervention and outcome types using inductive and deductive methods. Intervention details and directional findings for all outcomes were extracted.

Results

A total of 575 studies were included in the final analysis comprising 5,288,513 cases, 25,435 providers and patients, 2608 hospitals, across 50 countries, with 1221 outcomes extracted. Overall, the most common interventions were person-based, including education (38%) and policy (19%). Person-based interventions were more likely to improve interpersonal outcomes such as culture, professional development, and resilience. In contrast, system-based interventions, such as technology (15%), cognitive aids (11%), equipment (11%), standardization (4%), and environment redesign (2%), though less frequently implemented, were effective across all outcome types.

Conclusions

Although person-based interventions are widely implemented, system-based interventions generally have a greater impact on surgical outcomes. These results offer valuable insights for optimizing the alignment of interventions to outcomes.

A SEIPS-Based Analysis to Understand Safety Culture During Postpartum Hemorrhage

Background/Objectives: Maternal mortality occurs at alarming rates in the United States. In 2018, there were 17 maternal deaths for every 100,000 births-double that of other high-income countries, including France and Canada. Postpartum hemorrhage (i.e., excessive blood loss during delivery or within the 24 h following) is a leading cause of maternal mortality and is a treatable condition if identified and managed in a timely manner. One aspect of work that impacts patient care during postpartum hemorrhage is the safety culture. The safety culture is the beliefs, values, and norms shared by members of the organization that influence their actions and behaviors. In this study, we use the Systems Engineering Initiative for Patient Safety (SEIPS) model to understand and describe how the sociotechnical system shapes safety culture during postpartum hemorrhage. Methods: We conducted interviews and focus groups with 29 clinicians to describe the work system and the barriers and facilitators during postpartum hemorrhage. Then, we inductively categorized the barriers and facilitators into emergent properties of sociotechnical systems related to safety culture. Results: We identified 45 barriers and 158 facilitators into five emergent properties related to the safety culture (i.e., staffing, communication, organizational management and leadership, organizational processes, and teamwork). The participants identified more positive aspects than negative, suggesting that the safety culture positively influences their actions and behaviors. Conclusions: Our results indicate that safety culture could be improved by redesigning the work system to mitigate barriers related to staffing, communication, organizational management, and teamwork that hinder the safety culture.

Health IT Implementation and the Impact of the COVID-19 Pandemic on Clinician-IT Dynamics: Qualitative Study

BACKGROUND

The COVID-19 pandemic necessitated the rapid development and implementation of health ITs to support health care delivery. Health IT implementation is difficult at the best of times, due to complex sociotechnical challenges that vary across contexts and settings; however, it is currently unclear how the pandemic impacted health IT implementation processes. The aim of this study was to explore the impact of the pandemic on health IT implementation processes, including pre- and postimplementation phases, and identify the sociotechnical factors that shaped health IT implementation during an unprecedented circumstance.

OBJECTIVE

This study aimed to explore the impact of the pandemic on HIT implementation processes, including pre- and postimplementation phases, and identify the socio-technical factors that shaped health IT implementation during an unprecedented circumstance.

METHODS

Participants were from one of two teams: (1) health care staff members (doctors, nurses, nurse unit managers, and support staff members) from a virtual hospital in Australia; and (2) IT professionals within the broader health care organization assigned to the hospital. Participants took part in an interview or focus group from July to November 2022. Participants were asked to describe the process used for rapid health IT design and implementation during the COVID-19 pandemic. Qualitative data were analyzed thematically.

RESULTS

A total of 15 participants took part in the study. Both internal and external team structures, and the communication pathways that underpinned these, were reported to influence the health IT lifecycle, which in turn impacted outcomes, particularly when perceived normal ways of working were challenged during the pandemic. Across the pre-post lifecycle, preimplementation processes were viewed to be most impacted by the COVID-19 pandemic. Participants reported that their roles and responsibilities changed during health IT implementations in the pandemic, impacting co-design processes and highlighting the need for health IT implementation processes to cater for new work and the redistribution of existing work.

CONCLUSIONS

Our study uncovered the negative impact of the COVID-19 pandemic on team structures, communication pathways, and health IT preimplementation processes (project management and co-design). While health care organizations are keen to transition beyond the ways of working during the pandemic, it is imperative to learn from the health IT implementation successes and failures that occurred in the pandemic via process evaluations. Our evaluation offers learnings for research (an adapted interdisciplinary team communication framework), practice (the need for health care organizations to review their communication structures, IT staff skills, and proposed processes), and education (the need for better education and training of IT professionals working in clinical settings on health concepts) on health IT implementations as the world transitions to the "new norm."

A review of human factors and infusion pumps: lessons for procurement

Integrating advanced technologies like medical devices in healthcare is crucial for addressing critical challenges, but patient safety must remain the top priority. In modern clinical settings, medical devices, such as infusion devices used to administer fluids and drugs, carry risks from use errors, requiring a focus on usability and human factors engineering (HFE). Despite the significance of integrating HFE into technology selection processes, it is often overlooked. A review of five key articles demonstrates how applying HFE principles in procurement strategies can enhance device usability and patient safety. Although designed to reduce medication errors, infusion devices can still cause over-infusion or delays, indicating the need for improved safety features that must be considered in the context of sociotechnical systems. The reviewed studies suggest incorporating HFE in design, purchasing, and implementation to address these issues. The studies highlight various HFE methodologies, showing a wide variation in design, deployment, interpretation, and reporting. This comprehensive examination underscores the importance of standardised evaluations to ensure safer and more effective medical devices, emphasizing the essential role of HFE in advancing patient safety within healthcare settings.

Development and Evaluation of a Novel Resuscitation Teamwork Model for Out-of-Hospital Cardiac Arrest in the Emergency Department

STUDY OBJECTIVE

Cardiopulmonary resuscitation (CPR) is critical for out-of-hospital cardiac arrest patients but is prone to rapid changes and errors. Effective teamwork and leadership are essential for high-quality CPR. We aimed to introduce the Airway-Circulation-Leadership-Support (A-C-L-S) teamwork model in the emergency department (ED) to address these challenges.

METHODS

The study comprised 2 phases. The development phase involved reviewing CPR videos, categorizing problems, and formulating strategies using the Systems Engineering Initiative for Patient Safety model. Resuscitation tasks were organized into A-C-L-S domains using hierarchical task analysis. Equipment and environmental deficits were optimized ergonomically with a pit-crew style arrangement. Mnemonics enhanced teamwork and leadership. The evaluation phase assessed postimplementation ED resuscitation team performance, focusing on adherence, timeliness, and quality of A-C-L-S tasks.

RESULTS

The development phase produced a structured teamwork model, assigning tasks, tools, mnemonics, and positions based on A-C-L-S domains. The A-team manages the airway and optimizes end-tidal CO2 levels; the C-team focuses on high-quality chest compressions and defibrillation. Leadership coordinates resuscitation efforts using goal-directed mnemonics (DABCD2E3), whereas the S-team handles medications, timekeeping, and recording. The evaluation phase showed improvements in adherence and timeliness of A-C-L-S tasks, with sustained increases in chest compression fraction before mechanical CPR, from 67.2% preimplementation to 83.0% postimplementation, 89.1% after 1 year, and 86.1% after 2 years. Overall, chest compression fraction also improved from 81.7% to 88.6%, peaking at 92.2% after 1 year and maintaining 90.8% after 2 years.

CONCLUSION

The A-C-L-S teamwork model is feasible, applicable, and effective. Further research is needed to assess its influence on patient outcomes.

Key factors for sustainable working conditions in emergency departments: an EUSEM-initiated, Europe-wide consensus survey

BACKGROUND AND IMPORTANCE

Modern emergency medicine (EM) is a complex, demanding, and occasionally stressful field of work. Working conditions, provider well-being, and associated health and performance outcomes are key factors influencing the establishment of a sustainable emergency department (ED) working environment.

OBJECTIVES

This multinational European Delphi survey aimed to identify unequivocal major factors for good and poor ED working conditions and their possible effects on health care provider well-being.

DESIGN/SETTING AND PARTICIPANTS

A total of 18 experts from six European countries (Belgium, Finland, Germany, Italy, Romania, and the UK) covering three different hospital sizes (small, medium, and large) in their respective countries participated in the two-round Delphi survey. All panelists held leadership roles in EM.

OUTCOME MEASURES AND ANALYSIS

The first step involved conducting an extensive literature search on ED working conditions. The second step involved the first Delphi round, which consisted of structured interviews with the panelists. The survey was designed to obtain information concerning important working conditions, comments regarding work-life factors identified from the literature, and ratings of their importance. Interviews were transcribed and analyzed following a standardized protocol. In the second Delphi round, experts rated the relevance of items consolidated from the first Delphi round (classified into ED work system factors, provider health outcomes, and ED work-life intervention approaches).

RESULTS

A nearly unequivocal consensus was obtained in four ED work condition categories, including positive (e.g. job challenges, personal motivation, and case complexities) and negative (e.g. overcrowding, workflow interruptions/multitasking, medical errors) ED work conditions. The highly relevant adverse personal health events identified included physical fatigue, exhaustion, and burnout. Concerning intervention practices, the panelists offered a wide spectrum of opportunities with less consensus.

CONCLUSION

Work system conditions exert positive and negative effects on the work life of ED providers across Europe. Although most European countries have varying health care systems, the expert-based survey results presented herein strongly suggest that improvement strategies should focus on system-related external stressors common in various countries. Our findings lay the scientific groundwork for future intervention studies at the local and systemic levels to improve ED provider work life.

Understanding and measuring workplace violence in healthcare: a Canadian systematic framework to address a global healthcare phenomenon

BACKGROUND

Globally, healthcare institutions have seen a marked rise in workplace violence (WPV), especially since the Covid-19 pandemic began, affecting primarily acute care and emergency departments (EDs). At the University Health Network (UHN) in Toronto, Canada, WPV incidents in EDs jumped 169% from 0.43 to 1.15 events per 1000 visits (p < 0.0001). In response, UHN launched a comprehensive, systems-based quality improvement (QI) project to ameliorate WPV. This study details the development of the project's design and key takeaways, with a focus on presenting trauma-informed strategies for addressing WPV in healthcare through the lens of health systems innovation.

METHODS

Our multi-intervention QI initiative was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework. We utilized the SEIPS 101 tools to aid in crafting each QI intervention.

RESULTS

Using the SEIPS 3.0 framework and SEIPS 101 tools, we gained a comprehensive understanding of organizational processes, patient experiences, and the needs of HCPs and patient-facing staff at UHN. This information allowed us to identify areas for improvement and develop a large-scale QI initiative comprising 12 distinct subprojects to address WPV at UHN.

CONCLUSIONS

Our QI team successfully developed a comprehensive QI project tailored to our organization's needs. To support healthcare institutions in addressing WPV, we created a 12-step framework designed to assist in developing a systemic QI approach tailored to their unique requirements. This framework offers actionable strategies for addressing WPV in healthcare settings, derived from the successes and challenges encountered during our QI project. By applying a systems-based approach that incorporates trauma-informed strategies and fosters a culture of mutual respect, institutions can develop strategies to minimize WPV and promote a safer work environment for patients, families, staff, and HCPs.

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

BACKGROUND

Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response.

METHODS

This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery.

RESULTS

Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork.

CONCLUSIONS

In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

Influences on safety of intrapartum electronic fetal heart rate monitoring practices: a scoping review

OBJECTIVES

Suboptimal intrapartum electronic fetal heart rate monitoring using cardiotocography has remained a persistent problem (EFM-CTG). We aimed to identify the range of influences on the safety of using EFM-CTG in practice.

DESIGN

Scoping review to identify influences related to the practice of intrapartum EFM.

DATA SOURCES

MEDLINE, Embase, CINAHL, Web of Science, Scopus, British Nursing Index, Cochrane Library, from 1 January 2001 to 25 August 2024, and grey literature.

ELIGIBILITY CRITERIA

Articles that reported potential influences on the clinical practice of intrapartum EFM-CTG in hospital-based intrapartum maternity care settings, including primary studies, secondary analyses, reviews, reports, conference abstracts and investigations relevant to maternity and obstetrics, in English. Evaluations of technological modifications to traditional EFM-CTG monitoring and analysis were excluded.

DATA EXTRACTION AND SYNTHESIS

We extracted influences on EFM-CTG from the included studies. Findings were synthesised using a best-fit framework approach, structured using an existing 19-domain framework of contributory factors for patient safety incidents in hospitals.

RESULTS

142 articles and 14 reports were included. Our synthesis identified influences on EFM practice across all 19 domains of the contributory factors framework, including those relating to cognitive, social and organisational factors and interactions between professional work and tools used for fetal monitoring.

CONCLUSION

Reducing avoidable harm associated with electronic fetal monitoring requires a systems approach based on a sound understanding of the full range of influences on practice.

Incorporating Augmented Reality Patients Into Online Trauma Training to Support Mental Model Development: An Experimental Study

INTRODUCTION

Medical students find translating lessons from traditional lectures to caring for trauma patients challenging. We assess whether adding video-based virtual flashcards and videos of augmented reality-based trauma patients in an online learning environment improves performance.

METHODS

We performed a between-subject experimental study. Thirty-five medical students were randomly assigned to the control and experimental groups. The control group viewed a traditional online lecture. The experimental group viewed the same online lecture and received virtual flashcard training. Each virtual flashcard consisted of a video of a virtual patient, and examination questions about diagnoses, treatment, and disposition. The experimental group also viewed a video of a physician coach providing an expert assessment of the virtual patient. Simulation-based assessment was used to measure performance and knowledge. The evaluation consisted of the following 3 scenarios: a video of a simulated patient followed by multiple-choice questions, a free-text examination, and the writing of a Subjective, Objective, Assessment and Plan note. Differences in performance for 3 measures (diagnoses, therapeutic interventions, and disposition) were assessed for pre-post change in accuracy. For these 3 measures, we used a binary logistic regression model. We assessed perceptions of performance and the training experience with a survey.

RESULTS

The training intervention statistically significantly improved accuracy for diagnosis (P = 0.01) and self-reported performance (P < 0.01) compared with the control group. The themes for the experience were engaging, innovative, and valuing the expert's assessment, with 17 of 19 positive statements.

CONCLUSIONS

Adding virtual flashcards to traditional training significantly improved diagnostic accuracy while being engaging and innovative.

Development of a work systems stress questionnaire to predict job burnout: A mixed methods study based on a macroergonomics approach

Job burnout is a stress-related phenomenon that is a significant threat to the health and performance of organizations and employees. Interventions to ameliorate potentials for burnout have been limited by the lack of a comprehensive tool that considers work system stressors. Thus, the aim of this study was to develop a questionnaire for predicting job burnout based on the macroergonomics work system approach. The setting was a petrochemical company in South Iran. In the qualitative phase of this sequential exploratory mixed methods research, 971 meaning codes were extracted from fourteen one-to-one and seven focus group interviews (n = 59). The codes were subject to Directed Content Analysis, which yielded three themes and 15 dimensions, which were used to inform the development of reliable and valid questionnaire. Items for each of the dimensions were sourced from exiting scales. To test the developed Work System Stress Questionnaire (WSSQ) in terms of its ability to predict burnout, a survey which included demographic items, the WSSQ, and the Maslach Burnout Inventory was completed by 359 employees. Hierarchical linear regression modelling of the data indicated that Task Significance, Job Demands, Work-Life Conflict, and Work Schedule predicted Emotional Exhaustion, and altogether explained 58 % variance. Task Significance, Violence and Harassment, Work-Life Conflict, and Job Insecurity predicted the Depersonalization and explained 29 % variance. Decision Latitude, Welfare and Financial Facilities, Task Significance, and Structural Problems predicted Personal Accomplishment and explained 26 % variance. All 15 dimensions were valid (CVI range .73-.90) and reliable (Cronbach's alpha range .71-.93). The results confirm the ability of the WSSQ to explain more variance regarding job burnout than previous studies. In turn, the WSSQ will enable remedial actions to be put into place. It may also be useful for understanding the consequences associated with other organizational ergonomic variables that are related to job stress.

Healthcare workers' well-being and perspectives on support during the COVID-19 pandemic: a systematic review and meta-synthesis of qualitative studies

BACKGROUND

Since the outbreak of the COVID-19 pandemic, healthcare workers (HCWs) have faced multiple difficulties in their work and personal lives. However, most of the quantitative reviews have focused on the extent of the pandemic's impact on the HCWs and have thus failed to fully capture the HCWs' experiences and the complexity of the problems they encountered. Therefore, this qualitative systematic review elucidates the HCWs' challenges brought about by the pandemic, their perceptions of the existing support and the support that require further attention.

METHODS

The literature search spanned five databases: Scopus, PubMed, Web of Science, CINAHL and PsycInfo, targeting qualitative studies of HCWs' pandemic experiences from December 2019 to December 2023. These studies underwent strict quality and relevance assessment, emphasising critical appraisal and selection. Findings were unified through meta-synthesis, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study was registered in PROSPERO.

RESULTS

This study analysed 29 qualitative studies on HCWs' experiences during the pandemic and their perceptions of support, identifying four themes of HCWs' physical and mental well-being, the impact of the pandemic on their professional and personal lives, their work environments and the support they received. These themes encompassed 8 main categories and 25 codes. The research revealed that the pandemic and work conditions negatively influenced their health, affecting their professional and personal lives. Current support has lessened the pandemic's effects on HCWs but should also address future requirements like long-term psychological support.

CONCLUSION

The studies identified the challenges faced by HCWs during the pandemic, and the existing support. However, due to the complex interactions between the work and environmental factors, the effectiveness of the existing support remains challenging. To improve their effectiveness, the future support should target the interactions between the HCWs and the work system.

PROSPERO REGISTRATION NUMBER

CRD42023426238.

Work Systems Analysis of Emergency Nurse Patient Flow Management Using the Systems Engineering Initiative for Patient Safety Model: Applying Findings From a Grounded Theory Study

Background

Emergency nurses actively manage the flow of patients through emergency departments. Patient flow management is complex, cognitively demanding work that shapes the timeliness, efficiency, and safety of patient care. Research exploring nursing patient flow management is limited. A comprehensive analysis of emergency nursing work systems is needed to improve patient flow work processes.

Objective

The aim of this paper is to describe the work system factors that impact emergency nurse patient flow management using the System Engineering Initiative for Patient Safety model.

Methods

This study used grounded theory methodologies. Data were collected through multiple rounds of focus groups and interviews with 27 emergency nurse participants and 64 hours of participant observation across 4 emergency departments between August 2022 and February 2023. Data were analyzed using coding, constant comparative analysis, and memo-writing. Emergent themes were organized according to the first component of the System Engineering Initiative for Patient Safety model, the work system.

Results

Patient flow management is impacted by diverse factors, including personal nursing characteristics; tools and technology; external factors; and the emergency department's physical and socio-organizational environment. Participants raised concerns about the available technology's functionality, usability, and accessibility; departmental capacity and layout; resource levels across the health care system; and interdepartmental teamwork. Other noteworthy findings include obscurity and variability across departments' staff roles titles, functions, and norms; the degree of provider involvement in patient flow management decisions; and management's enforcement of timing metrics.

Conclusions

There are significant barriers to the work of emergency patient flow management. More research is needed to measure the impact of these human factors on patient flow outcomes. Collaboration between health care administrators, human factors engineers, and nurses is needed to improve emergency nurse work systems.

Association of the COVID-19 Pandemic on Employment Status Change for Practicing Pharmacists

OBJECTIVE

The COVID-19 pandemic resulted in health care workers experiencing temporary or permanent changes in employment due to layoffs, quits, and postpandemic increased job demand. Analyzing the association of the COVID-19 pandemic with employment changes and results of changes for practicing pharmacists and understanding the associations with demographic and work-related factors could inform practice, policy, and educational programs. This study aimed to explore the frequency, characteristics, and results of employment status changes (ESCs) experienced by pharmacists practicing pharmacy in March 2020 (ie, the start of the COVID-19 pandemic).

METHODS

A descriptive, cross-sectional survey research design was used to collect data from a random sample of 93,990 licensed pharmacists in the United States. The study team developed an online survey questionnaire designed to assess the impacts of the COVID-19 pandemic on pharmacists' work and work-life. The survey items used for this study related to ESCs, work-life characteristics, work characteristics in March 2020 and 2022, and demographic variables. A total of 4947 usable responses were received between November 2022 and January 2023.

RESULTS

Overall, 36.4% of respondents reported experiencing an ESC and approximately 70% of those reporting an ESC reported experiencing just 1 ECS. Overall, 39.5% of respondents who experienced an ESC stopped working (ie, were unemployed) pursuant to an ESC. Respondents who experienced an ESC reported significantly lower levels of work exhaustion and interprofessional disengagement and significantly higher levels of professional fulfillment in their current employment than respondents that did not experience an ESC.

CONCLUSION

The overall increase in demand for workers in the health care sector appeared to provide opportunities for pharmacists, especially pharmacists with 1 to 10 years of experience, to change their employment situation, resulting in better work-life characteristics. Given projections of a pharmacist shortage, research, policy, and educational programs could determine the best practices to improve work settings and the work-life characteristics of practicing pharmacists to improve the health of the current pharmacist workforce.

Investigating pediatric nurses' perceptions of factors contributing to MAEs at Yendi hospital, Ghana

BACKGROUND

Medication administration errors (MAEs) are a critical concern in pediatric healthcare, contributing to adverse drug events (ADEs) and negatively impacting patient health.

OBJECTIVES

This study explores pediatric nurses' perceptions of factors contributing to MAEs at Yendi Municipal Hospital to develop interventions enhancing patient safety.

METHODS

A descriptive cross-sectional survey was conducted among 143 nurses at Yendi Municipal Hospital using structured questionnaires. Data were analysed using SPSS 26.0 and Excel 2016. Bivariate analysis examined relationships between socio-demographic characteristics and MAEs.

RESULTS

Contributing factors to MAEs included inadequate training (91.6%), misunderstanding medical abbreviations (88.8%), poor supervision (92.3%), eagerness to sign out shifts (70.6%), improper handover (88.8%), inadequate staff (77.6%), dosage miscalculations (83.9%), and illegible handwriting (81.8%). Significant associations were found between MAEs and the type of unit/ward (X²=6.25, p = 0.012) and educational level (Fisher Exact test = 4.20, p = 0.036).

CONCLUSION

Inadequate training, poor supervision, and communication issues are major contributors to MAEs in pediatric settings. Targeted interventions can significantly improve patient safety and care quality.

Home self-management of type 2 diabetes with diabetes technologies in northern France: a focused ethnographic study protocol

INTRODUCTION

Type 2 diabetes is a chronic condition associated with impaired glucose tolerance and a high prevalence of comorbidity, polypharmacy and medication safety incidents. Little is known about the patient work associated with using diabetes management technologies by patients and their informal caregivers at home. This study aims to apply a systems engineering approach to better understand this work.

METHODS AND ANALYSIS

This is a qualitative focused ethnographic study using interview and photography. Adults, living independently at home, with type 2 diabetes who have been using insulin as part of their treatment regimen for a minimum of 6 months and who are using at least one diabetes management technology without support of a professional at home are eligible for inclusion. Participants will be recruited through advertisements on social media, in diabetes clinics and by contacting associations of persons living with diabetes and diabetes specialists. Participant consent will be taken, interviews will be undertaken in the participant's home, audio-recorded and photographs securely saved. The Systems Engineering Initiative for Patient Safety (SEIPS) model will frame the data coding and we will develop new codes to accommodate data outside the SEIPS model. Results will be interpreted to produce a description of work processes, work system elements and interactions that support or jeopardise the achievement of safety. This protocol will follow the consolidated criteria for reporting qualitative research checklist for the reporting of qualitative research interviews.

ETHICAL CONSIDERATIONS AND DISSEMINATION

This protocol was approved by the University of Lille's Behavioural Sciences Ethics Committee. The study will comply with data protection legislation: the protocol has been declared by the Data Protection Officer of the University of Lille to the National Commission on Informatics and Liberty. We plan to disseminate our findings via presentations at relevant patient/public, professional, academic and scientific meetings, and publish in a peer-reviewed journal.

The Application of Human Factors Approaches to Improve Safety, Efficiency and Well-being in Urology: A Systematic Scoping Review

OBJECTIVE

To elucidate the application of HF approaches within urology to improve clinical work-system function via a systematic scoping review. Human Factors (HF) plays an integral role to improving safety, efficiency, and well-being by optimizing work-system interactions. Despite its established application across various high-risk industries, the systematic exploration of HF methods applied within urology remains limited.

METHODS

A scoping review of HF interventions implemented within urologic care from 1980 to 2023 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Web of Science, PubMed, and OVID Medline databases were searched. Database searching resulted in 10,850 articles, after systematic review, 22 studies were included.

RESULTS

The included studies predominantly originated from the United States and covered diverse areas of urology, including surgical procedures, diagnostics, and patient care. Interventions varied widely from ergonomic equipment implementations to modifications in clinical processes and team dynamics. Most studies utilized predetermined interventions based on prior literature or experiential anecdotes (15, 65.22%), while a smaller subset employed data-driven strategies to tailor interventions (8, 34.7%). The HF methods employed included questionnaires, retrospective reviews, observations, and physical measurements, targeting improvements in patient experiences, operational efficiencies, and clinical outcomes.

CONCLUSION

This review underscores the emergent role of HF in urology, highlighting a broad spectrum of interventions and methodological approaches that contribute to system optimization. Future endeavors should focus on collaborative efforts to develop standardized HF applications in urology, promoting a safer, more efficient, and clinician-friendly environment.

I-SIRch: AI-powered concept annotation tool for equitable extraction and analysis of safety insights from maternity investigations

Background

Maternity care is a complex system involving treatments and interactions between patients, healthcare providers, and the care environment. To enhance patient safety and outcomes, it is crucial to understand the human factors (e.g. individuals' decisions, local facilities) influencing healthcare. However, most current tools for analysing healthcare data focus only on biomedical concepts (e.g. health conditions, procedures and tests), overlooking the importance of human factors.

Methods

We developed a new approach called I-SIRch, using artificial intelligence to automatically identify and label human factors concepts in maternity investigation reports describing adverse maternity incidents produced by England's Healthcare Safety Investigation Branch (HSIB). These incident investigation reports aim to identify opportunities for learning and improving maternal safety across the entire healthcare system. Unlike existing clinical annotation tools that extract solely biomedical insights, I-SIRch is uniquely designed to capture the socio-technical dimensions of patient safety incidents. This innovation enables a more comprehensive analysis of the complex systemic issues underlying adverse events in maternity care, providing insights that were previously difficult to obtain at scale. Importantly, I-SIRch employs a hybrid approach, incorporating human expertise to validate and refine the AI-generated annotations, ensuring the highest quality of analysis.

Findings

I-SIRch was trained using real data and tested on both real and synthetic data to evaluate its performance in identifying human factors concepts. When applied to real reports, the model achieved a high level of accuracy, correctly identifying relevant concepts in 90% of the sentences from 97 reports (Balanced Accuracy of 90% ± 18% (Recall 93% ± 18%, Precision 87% ± 34%, F-score 96% ± 10%). Applying I-SIRch to analyse these reports revealed that certain human factors disproportionately affected mothers from different ethnic groups. In particular, gaps in risk assessment were more prevalent for minority mothers, whilst communication issues were common across all groups but potentially more for minorities.

Interpretation

Our work demonstrates the potential of using automated tools to identify human factors concepts in maternity incident investigation reports, rather than focusing solely on biomedical concepts. This approach opens up new possibilities for understanding the complex interplay between social, technical and organisational factors influencing maternal safety and population health outcomes. By taking a more comprehensive view of maternal healthcare delivery, we can develop targeted interventions to address disparities and improve maternal outcomes. Targeted interventions to address these disparities could include culturally sensitive risk assessment protocols, enhanced language support, and specialised training for healthcare providers on recognising and mitigating biases. These findings highlight the need for tailored approaches to improve equitable care delivery and outcomes in maternity services. The I-SIRch framework thus represents a significant advancement in our ability to extract actionable intelligence from healthcare incident reports, moving beyond traditional clinical factors to encompass the broader systemic issues that impact patient safety.

A Combined Telemedicine and Ambulatory Wound Care Team Intervention for Improving Cross-Sector Outpatient Chronic Wound Management: Protocol for the Mixed Methods TELE-AMBUS Research Project

BACKGROUND

There is a growing prevalence of nonhealing wounds and chronic diseases in society, and there is an associated need for wound management solutions that include the use of telemedicine. A broad spectrum of factors influences the planning and execution of interventions within telemedicine in chronic wound management, spanning organizations, technologies, and individuals, including professionals and patients. The Telemedicine and Ambulatory Wound Care Team (TELE-AMBUS) project applies a whole-system research approach to account for this spectrum of factors.

OBJECTIVE

The primary objective of this study was to explore and analyze the implementation and consequences of an outpatient wound management model, comprising 2 interconnected quality improvement interventions (ie, telemedicine and ambulatory wound care team) aimed at older and vulnerable patients with chronic wounds, across the specialist and primary health care sectors. Embedded in this objective is the aim to improve the competence levels of health care providers and, consequently, the service quality of outpatient wound management across specialist and primary health care services.

METHODS

This project examines the implementation and consequences of an outpatient wound management model through a combined process and economic evaluation research strategy. A sociotechnical system theory approach and multiple work package design support the examination. The project uses observations, conversations, interviews, and economic assessments to gather rich, in-depth insights and understanding on why and how the new wound management model contributes to a change or not compared with the traditional treatment model.

RESULTS

The project has been funded from 2021 to 2025. Baseline interviews have been conducted since April 2022 and concluded in January 2024. Fieldwork, including nonparticipant observations, semistructured interviews, and informal conversations, has been conducted since November 2022 and is expected to conclude in March 2025. In parallel and as part of the cost-effectiveness analyses, time usage data on the outpatient and regular clinical models are being gathered during the fieldwork.

CONCLUSIONS

We applied a whole-system approach in multiple ways, that is, to design or inform our fieldwork and to explore, evaluate, and translate project findings into practice across services. To our knowledge, this approach has not been undertaken in telemedicine in chronic wound management literature and associated human factors and ergonomics research. Thus, our approach can produce both original and novel research and theoretical results internationally.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55502.