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The blunt end of a complex system controls the resources and constraints that confront the practitioner at the sharp end.
Contexts in source publication
Context 1
... the research results shift attention away from the people closest to the accident and toward the blunt end of the system where regulatory, administrative, and organizational factors reside. Complex systems such as health care or aviation have both a sharp end and a blunt end ( Figure 3). The sharp end is where practitioners interact directly with the hazardous process in their roles as pilots, mechanics, air traffic controllers, and, in medicine, as nurses, physicians, technicians, pharmacists and ...
Context 2
... mission of the National Patient Safety Foundation is to measurably improve patient safety in the delivery of health care. The Foundation was launched by the American Medical Association in 1997 as an independent not-for-profit research and education organization comprising a broad partnership representing consumer advocates; health care providers; health product manufacturers; employers and payers (public and private); researchers; and regulators and policy-makers. NPSF serves as the forum for a diverse group of concerned individuals to think and talk about the issues and impediments to patient safety. The NPSF seeks to be a catalyst for action and a vehicle to support change and track improvements in patient safety. Table of Contents v Tables and Figures Tables Table 1 "Celebrated" medical accidents Table 2 The sequence of events in the investigation of four operating room incidents involving misadministrations via an infusion device. Figure 1 The view of patient safety based on celebrated cases. Figure 2 Hindsight does not equal foresight. Figure 3 The blunt end of a complex system controls the resources and constraints that confront the practitioner at the sharp end Figure 4 A stage in an antibody identification problem using an enhanced electronic version of the original paper form with computer-based critiquing. Figure 5 Protocol describing the interaction between anesthesiologists and an infusion device during an operating room ...
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Was in den letzten zehn Jahren erreicht werden konnte und wohin die Reise künftig gehen muss, diskutierten 350 Teilnehmer in Berlin. Unter dem Motto „Patientensicherheit – Die Zukunft im Blick“ fand am 16. und 17. April 2015 die 10. Jahrestagung des Aktionsbündnisses Patientensicherheit (APS) statt.
Citations
... Although several adverse events reported here seem to have caused due to user error, the "new view" on human factors engineering points out human error as a symptom of a flawed system [29], [30]. Human error is associated with characteristics and relationships between the user tasks, user tools, and the operating environment [31]. ...
ABSTRACT Background: Usability problems due to user interface design can result in acute consequences for end users and interrupt the smooth administration of medical treatments. Therefore, designers must consider design guidelines at different stages of product development. Manufacturer and User Facility Experience (MAUDE) is a source of publicly available data containing adverse events reports and have been used extensively in research domain. Methods: This study conducted a retrospective review of MAUDE data for Graphic User Interface (GUI) problems leading to "injury" and "death" reported from January 2018 to December 2021 under device problem categories a) Inadequate user interface and b) Use of incorrect control settings. After filtering through exclusion criteria, 229 events were selected to examine further GUI problems. Findings: It was determined that 76(33.2%) events were associated with GUI problems, 51(22.2%) events were inconclusive, 98(42.7%) events were non-GUI related, and 4(1.8%) events were due to other software problems. GUI problems were due to user error (input error, incorrect settings, and inadvertent user action), undesired system action, lack of appropriate system feedback, mismatch between system and user expectation, user not in control, GUI workflow, and learnability. Conclusion: This paper demonstrates the viability of using the MAUDE database to collect user interface design insights to develop guidelines for the design of future medical devices. The insights discussed in this paper hint at usability evaluation to focus more on those tasks where use errors occur the most. Furthermore, events from the MAUDE source help include real-life examples in relevant design guidelines, which aids designers in relating to their design context[1], especially in developing scenarios and context to build extreme scenarios in product design.
... However, IRSs have largely been ineffective in improving care quality and patient safety (Sujan, 2015). One major criticism is that they represent a narrow approach of learning about work through the lens of negative outcomes (Cook et al., 1998). Everyday performance is characterized by the same adaptive processes, including workarounds, adjustments, preventative measures, and other coping mechanisms, regardless of the type of outcome (Hollnagel, 2014). ...
The fields of Cognitive Engineering (CE) and Decision Making (DM) have made exceptional contributions to our understanding of complex sociotechnical systems; however, it can be difficult to apply research and findings from CE work to drive Systems Development (SD). This panel discussion examines the connective tissue between the worlds of CE research and SD practice. Panelists with backgrounds across CE and SD will provide generalizable examples of how to apply specific CE theories, methods, and principles (e.g. naturalistic decision making, macrocognition, and resilience engineering), to generate various SD products (e.g. system requirements and designs). The goal of the panel will be to provide useful examples, and spur discussion about means to more readily translate research into practice.
... For example, the classification of a report before it is analyzed may result in it being assigned to completely different categories than would be the case after analysis. A forgotten insulin administration, for example, may be considered an active failure due to inattention, while-after analysis-one may realize that it is also the result of a complex interplay between organizational factors, such as the usability of the medication While CIRS can be used to identify hazards, previous research has concluded that the distribution of incident types cannot be used to assess the severity of reported problems or to compare them with one another 66 : different incident types' reporting rates may reflect different motivational factors; errors in medication administration may be more readily reported than complex diagnostic errors that become evident only over time. In addition, the culture may be inducive to reporting or not, so that higher reporting rates do not reflect greater problems, but a better reporting culture. ...
Introduction:
Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.
Methods:
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths.
Results:
We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus.
Conclusions:
This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner.
... Among the workforce, this can result in fear of blame, reprimand, and associated social and socio-legal consequences (Anderson et al., 2013;Ashcroft et al., 2006;Sujan, 2015;Waring, 2005). From a learning perspective, retrospective analysis of negative occurrences or outcomes is fraught with hindsight bias, where the adverse or potentially adverse consequence leads to a tendency of the analyst to undervalue the contextual factors that influenced or necessitated the course of actions taken prior to the event (Cook et al., 1998;Wears & Cook, 2004). As a corollary, there is an underappreciation of the contextual factors that influence adaptive responses. ...
... This has the virtue of not requiring someone to complete it immediately after cases and may result in richer input since respondents should not be as time constrained. While we have not done this in our implementation so far, the visibility of information from individual reports back to the professional community has been acknowledged as one of the main factors underlying the sustained success of the Aviation Safety Reporting System (ASRS) (Cook et al., 1998). ...
Event reporting systems are widely prevalent across healthcare organizations and are used as tools to learn about a variety of negative outcomes and near misses. As artifacts of the traditional approach to safety, their scope is mostly limited to learning how things go wrong based on specific episodes or incidents. In order to expand the learning focus to include descriptions of everyday contexts characterized by variability and adaptation, the Resilience Engineering Tool to Improve Patient Safety (RETIPS) was developed. RETIPS was implemented on a pilot basis focusing on anesthesia residents at a large multispecialty hospital. Participants self-reported lived experiences of workflows and adaptations in ‘everyday’ situations, regardless of whether these narratives were associated with any incidents. The chapter reflects on the authors’ experience of developing the tool and implementing at the hospital, and offers insights for transforming organizational learning from traditional approaches toward more proactive learning of how things work in daily practice.
... Six chapters study particular applications and distil principles that have a potential use beyond the particular area that were studied. Three study healthcare, which has been an area of interest from the outset, pioneered by practitioner/researchers including Cook (Cook & Woods, 1996;Cook et al., 1998), and Wears et al., 2006). The successful application of resilience engineering principles to the thorny issue of patient safety has already become an active field of study in itself (e.g., Hollnagel et al., 2019). ...
... This has the virtue of not requiring someone to complete it immediately after cases and may result in richer input since respondents should not be as time constrained. While we have not done this in our implementation so far, the visibility of information from individual reports back to the professional community has been acknowledged as one of the main factors underlying the sustained success of the Aviation Safety Reporting System (ASRS) (Cook et al., 1998). ...
Resilience is defined as “the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions” (Woods & Hollnagel, 2006, p. xxxvi). If there was ever an industry that has demonstrated this ability, it is the aviation industry. The industry has continually demonstrated the ability to adjust and sustain operations after unexpected events, and has improved both reliability and safety in the midst of increasing complexity of the aircraft, economic challenges, and aviation systems that are dependent on a range of different organizations to succeed (Høyland & Aase, 2008). It has been proposed that resilience is a characteristic of system performance, not the system itself (Hollnagel, 2011), and therefore it is fitting to examine the aspects of aviation that enable it to demonstrate resilient performance. This chapter presents a discussion of resilient performance in aviation, including what resilient performance looks like in aviation, how it is currently achieved, and methods to further advance resilient performance in the future.
... Rather than seeing safety as the absence of preventable harm, contemporary safety science introduces the view that failure and success originate from the same kinds of processes of performance variability in complex systems 6,7 and the idea that symmetrical cause-and-effect relationships rooted in a linear and reductionist ontology fall short of explaining harm in complex and adaptive systems such as health care. 8 Wiig and colleagues 9 suggest that health care investigations of preventable harm should experiment with a variety of approaches to strengthen patient safety and should not be limited by root-cause analysis. ...
Objectives:
The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm.
Method:
A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy.
Results:
The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization.
Conclusions:
The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.
... Series of medical errors have been revealed recently, medication errors which can be prevented before causing any harm to the patient [1]. This motivates health care professionals and governmental bodies to avoid such errors before occurrence [2]. Errors may result from the medication process during prescribing, transcribing, dispensing, or administering [2,3]. ...
... This motivates health care professionals and governmental bodies to avoid such errors before occurrence [2]. Errors may result from the medication process during prescribing, transcribing, dispensing, or administering [2,3]. Administration and prescribing errors are the most common types of medication errors in hospitals [4]. ...
Aims: There are series of medical errors that can be prevented by taking precautions. Therefore, the study evaluates the impact of the electronic prescribing system on prescription errors. Study Design: A pre-post study design was conducted. Place and Duration of Study: The study was conducted at outpatient pharmacy services of a teaching hospital in Jeddah city. Methodology: Prescriptions were evaluated for the presence of the essential prescription elements such as patient information, drug name, dose, frequency, strength, and other prescription completeness parameters. Results: In the pre-intervention study, 1182 handwritten prescriptions were evaluated, and 6627 errors were detected from these prescriptions. The length of the pre-and post-intervention period was two weeks each. The most prevalent prescribing errors were that of medications written without defined dosage forms were recorded 1653 (55.90%) time followed by prescriptions written by trade names 1493 (22.5%), without route of administration 1266 (19.1%), and without specified duration 1009 (15.2%). However, 1512 prescriptions were evaluated in the post-intervention study, among which 339 errors were detected. The errors included prescriptions written without diagnosis (5.09%), or without doctor’s name or stamp (1.52%), written by trade names (4.49%), without defined dosage forms (4.29%), and without specified duration (2.84%). Conclusion: The study concluded that E-prescribing eliminated prescription errors that resulted from handwritten prescriptions.
... In the late 1990s, patient safety evolved into discipline of its own in healthcare [1]. Today, patient safety is defined by the World Health Organization (WHO) as; "the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum" [2]. ...
Background:
As healthcare becomes increasingly complex, new methods are needed to identify weaknesses in the system that could lead to increased risk. Traditionally, the focus for patient safety is to study incident reports and adverse events, but that starting point has been contested with a new era of safety investigations: the analysis of everyday clinical work, and the resilient healthcare. This study introduces a new approach of system monitoring as a way to strengthen patient safety and has focused on discharge in psychiatry as a risk for adverse outcomes. The aim was to analyse a psychiatric clinic's everyday 'normal' performance variability of discharge from inpatient psychiatric care to outpatient care.
Method:
A retrospective longitudinal correlation study with a strategic selection. Data consist of 70,797 patient visits within one psychiatric clinic, and the visits were compared between 81 different wards in Stockholm County by using a model of time-lapse visualization.
Results:
The time-lapse visualization shows a discrepancy in types of visits and the proportion of cancelled visits to the outward units. 42% of all patients that were scheduled as an outward patient, did not complete this transition, but instead, they revisit the clinics' emergency ward and did not receive the planned care treatment. The patients who visit the emergency ward instead of their planned outpatient visit did this within 20 days.
Conclusions:
The findings show a potential increased demand for emergency psychiatric care from 2010 to 2018 within the clinic. It also suggests that the healthcare system creates a space of temporal as well as functional variability, and that patients use this space to adapt to their changing conditions. This understanding can assist management in prioritising allocation of resources and thereby strengthen patient safety. Today's incident reporting systems in healthcare are ineffective in monitoring patterns of more cancelled visits in outward units and sooner visit to the emergency ward. By using time-lapse visualization of patient interactions, stakeholders might analyse current-, and estimate future, stressors within the system to identify and understand potential system migration towards risk in healthcare. This could help healthcare management understand where resources should be prioritized.
... The first perspective, also known as "the old view," points out human error as the cause of system failure. In this perspective, human error is responsible for the accidents in engineering systems [15,16]. Engineering systems are designed and built to be safe. ...
... Therefore, engineering systems need protection from users through training, standardization of procedures, and discipline. The second perspective, also known as "the new view," points out human error as a symptom of a defective system [15,16,18]. In this perspective, engineering systems are not safe because systems are contradictions between multiple goals that are being pursued simultaneously. ...
Engineers have developed different design methodologies capable of identifying failure modes of engineering systems. The most common methods used in industry are failure modes and effects analysis, and failure modes effects and criticality analysis. Nevertheless, such methodologies have a significant limitation regarding incorporating the final user in the analysis and are not suited to identifying potential failure modes caused by physical human–system interactions. Engineering methods usually have a lack of sufficient attention to human–system interactions during the early design stages, even though introducing human factors principles is recognized as an essential analysis during the design process. As a result, designers rely on developing detailed and expensive physical or virtual prototypes to evaluate physical human–system interactions and identify potential failure modes caused by such interactions incorporating design modifications after a prototype is developed can be time-consuming, costly, and if significant changes are needed, the entire prototype requires to be constructed again. Identifying system–user interactions and possible failure modes associated with such interactions before developing a prototype can significantly improve the design process. In previous work, the authors introduced the function–human error design method (FHEDM), a tool capable of distinguishing possible human–system interaction failure modes using a functional basis framework. In this work, we examined the implementation of FHEDM within 148 products extracted from the design repository. The results are grouped in the composite function–user interaction error (FUIE) matrix, which can be used as a preliminary design database presenting information regarding the possible human error present in function-flow combinations.
... Its prominence is fueled by an expanding body of literature that shows a high incidence of error in medicine, coupled with well-publicized medical error cases by the media that have raised public concern about the safety of modern health care delivery. 29 There has to be a check and balance mechanism that maintains the doctor-patient trust while addressing medico legal issues, media, and public safety. Patients shall feel safe and professionals shall not be frustrated. ...
Background: Surgical and medical errors are not uncommon but the majority are often subtle. Even in highly developed countries, medical error is the third highest leading cause of death. Patient harm from medical error can occur at an individual or a system level. Methods and materials: A decision data base of the Health Professionals Ethics Committee that reviews medical error complaints and malpractice claims available at Federal level was used. Descriptive statistics were used to describe and see trends observed over seven years, 2011–2017, inclusive. Numbers from National data were used to see the 10-year trend.
Results: In the seven-year review period, the committee made a final decision on 125 complaints. Over 20 types of health professions were present. Death was the issue in 72 (57.6%) of them and 27 (21.6%) of the claimants associated the error with bodily injury. The majority of complaints, 94 (75.2%), were from hospitals. Most of the complaints were surgical-related and emerged from the operation room (90/125, 72%). Forty-one (28.1%) complaints were against obstetricians and gynecologists, 15 (10.2%) against general sur- geons, and eight (5.5%) against orthopedic surgeons. Among all complaints, in 27 (21.6%) claims, actual ethical breach or medical error was found. Gross professional negligence was observed in four of these and the professionals were permanently prevented from practicing medicine at all.
Conclusion: In Ethiopia, an increasing number of applications is filed for investigation of possible surgical/medical error. Most of the complaints did not result in payouts; only one fifth benefited the plaintiff. Some specialties are particularly at high risk for accusations. Recommendations: The increasing number of complaints filed for medical error investi- gation in Ethiopia needs deeper investigation by all stakeholders. Routine patient safety measures have to be exercised to prevent/decrease incidents of surgical/medical errors. Keywords: surgical and medical errors, ethics committee, health professionals, Ethiopia
