Ayse Gurses

Johns Hopkins Medicine | JHUSOM

Objective To develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults. Design, settings and participants Measures were developed and evaluated in a multisite prospective observational study of older adults (≥65 ye...

Background Previous research and safety advocacy groups have proposed various behaviors for older adults to actively engage in medication safety. However, little is known about how older adults perceive the importance and reasonableness of these behaviors in ambulatory settings. Objective This study aimed to assess older adults’ perceptions of the...

Background We developed the Hospital-to-Home-Health Transition Quality (H3TQ) Index for skilled home healthcare (HH) agencies to identify threats to safe, high-quality care transitions in real time. Objective Assess the validity of H3TQ in a large sample across diverse communities. Research Design A survey of recently hospitalized older adults re...

Background Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with...

BACKGROUND Previous research and safety advocacy groups have proposed various behaviors for older adults to actively engage in medication safety. However, little is known about how older adults perceive the importance and reasonableness of these behaviors in ambulatory settings. OBJECTIVE This study aimed to assess older adults’ perceptions of the...

Objective To synthesize evidence and identify gaps in the literature on environmental cleaning and disinfection in the operating room based on a human factors and systems engineering approach guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model. Design A systematic scoping review. Methods Following the Preferred Reporting...

Background Skilled home healthcare (HH) provided in‐person care to older adults during the COVID‐19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH service...

BACKGROUND Preventable patient harms from medications are significant threats to patient safety in ambulatory and community settings, especially among community-dwelling older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning basics of medication self-m...

Objectives Community-dwelling older adults taking 5 or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations, such as the Food and...

Background Our aim was to understand actions by primary care teams to improve medication safety. Methods This was a qualitative study using one-on-one, semistructured interviews with the questions guided by concepts from collaborative care and systems engineering models, and with references to the care of older adults. We interviewed 21 primary ca...

Background: Environmental cleaning is critical in preventing pathogen transmission and potential consecutive healthcare-acquired infections. In operating rooms (ORs), multiple invasive procedures increase the infectious risk for patients, making proper cleaning and disinfection of environmental surfaces of paramount importance. A human-factors engi...

Background: The use of large-scale data and artificial intelligence (AI) to support complex transplantation decisions is in its infancy. Transplant candidate decision-making, which relies heavily on subjective assessment (ie, high variability), provides a ripe opportunity for AI-based clinical decision support (CDS). However, AI-CDS for transplant...

Objective: Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implemen...

Objectives Access to patient information may affect how home-infusion surveillance staff identify central-line–associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards. Design Qualitative study using semistructured inter...

Older adults and caregivers play an essential role in medication safety; however, self-perception of their and health professionals’ roles in medication safety is not well-understood. The objective of our study was to identify the roles of patients, providers, and pharmacists in medication safety from the perspective of older adults. Semi-structure...

Background Inflammatory bowel disease (IBD) commonly leads to iron deficiency anemia (IDA). Rates of screening and treatment of IDA are often low. A clinical decision support system (CDSS) embedded in an electronic health record could improve adherence to evidence-based care. Rates of CDSS adoption are often low due to poor usability and fit with w...

Infection prevention and surveillance training approaches for home infusion therapy have not been well defined. We interviewed home infusion staff who perform surveillance activities about barriers to and facilitators for central line-associated bloodstream infection (CLABSI) surveillance and identified barriers to training in CLABSI surveillance....

Background Infection preventionists who perform surveillance for central line-associated bloodstream infections (CLABSIs) in hospitals receive training in application of rigorous surveillance definitions. However, in the home infusion setting where CLABSIs also occur, the approach for training and methods to perform surveillance has not been well d...

Effective and practical infection prevention and control (IPC) processes and protocols are vital to safety of patients and health care workers (HCWs) as well as improving public health. This interdisciplinary panel, composed of experts in IPC, public health, medicine, and human factors engineering (HFE), will discuss the urgent need for developing...

Background: Emergency departments (EDs) are complex, sociotechnical, high-paced, safety-critical work systems that have been disproportionately affected by the COVID-19 pandemic. Despite training, consistent compliance with recommended PPE use during COVID-19 pandemic has been challenging. Healthcare workers (HCWs) have had adapt to overcome these...

Background: Infection prevention and control (IPC) protocols and guidelines are important quality management tools for educating care professionals and standardizing care processes. However, most of the actual care (ie, work as done) differ from protocol recommendations (ie, work as imagined). No tool or set of criteria has been established for how...

Background : The effectiveness of PPE in preventing self-contamination of healthcare workers (HCWs) and transmission of pathogens (airborne and contact) in the emergency department (ED) is highly dependent on consistent, appropriate use of and other interactions (eg, storing, cleaning, etc) with the PPE. Pre–COVID-19 studies focused primarily on in...

Objective This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related. Background Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts....

Racial and ethnic disparities persist in access to the liver transplant (LT) waitlist, however there is limited knowledge about underlying system level factors that may be responsible for these disparities. Given the complex nature of LT candidate evaluation, a human factors and systems engineering approach may provide insights. We recruited partic...

Objectives: Care transitions pose a high risk of adverse drug events (ADEs). We aimed to identify hazards to medication safety for older adults during care transitions using a systems approach. Methods: Hospital-based professionals from 4 hospitals were interviewed about ADE risks after hospital discharge among older adults. Concerns were extrac...

Background Patients discharged to the home on home-based outpatient parenteral antimicrobial therapy (OPAT) perform their own infusions and catheter care; thus, they require high-quality training to improve safety and the likelihood of treatment success. We describe our experience piloting an educational toolkit for patients on home based OPAT. Me...

Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data include...

Background Barriers for home infusion therapy central line associated bloodstream infection (CLABSI) surveillance have not been elucidated and are needed to identify how to support home infusion CLABSI surveillance. We aimed to (1) perform a goal-directed task analysis of home infusion CLABSI surveillance, and (2) describe barriers to, facilitators...

Background: Inappropriate C. difficile testing has adverse consequences for the patient, hospital, and public health. Computerized Clinical Decision Supports (CCDS) in the Electronic Health Record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into the healthcare providers' (H...

Background Healthcare workers (HCWs) not adhering to physical distancing recommendations is a risk factor for acquisition of severe acute respiratory coronavirus virus 2 (SARS-CoV-2). The study objective was to assess the impact of interventions to improve HCW physical distancing on actual distance between HCWs in a real-life setting. Methods HCWs...

While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (sur...

Objective Despite the importance of physical distancing in reducing SARS-CoV-2 transmission, this practice is challenging in healthcare. We piloted use of wearable proximity beacons among healthcare workers (HCWs) in an inpatient unit to highlight considerations for future use of trackable technologies in healthcare settings. Materials and Methods...

Objective: Our objective was to characterize tasks required for patient-performed antibiotic medication management (MM) at the hospital-to-home transition, as well as barriers to and strategies for patient-led antibiotic MM. Our overall goal was to understand patients' role in managing antibiotics at the hospital-to-home transition. Methods: We...

Deprescribing is the process of withdrawing or replacing medications to improve outcomes and reduce medication-associated risks. Deprescribing, though traditionally the domain of healthcare professionals, is now receiving attention from human factors experts. In turn, the deprescribing community is gaining an appreciation for human-centered design...

Efforts to ensure research integrity has mostly focused on research misconduct. However, the complexity of research operations and processes makes research work also prone to unintentional errors. To safeguard against errors and their consequences, strategies for error reduction, detection, and mitigation can be applied to research work. Nurturing...

Health information technologies (HIT) can support care and coordination of pediatric trauma patients. This study adapted to a remote usability study protocol to test a HIT prototype that was designed using a participatory design process. The participants were mostly successful interacting with the prototype and were able to locate and understand ne...

BACKGROUND The availability of patient outcomes-based feedback is limited in episodic care environments like the emergency department (ED). Emergency medicine (EM) clinicians set care trajectories for a majority of hospitalized patients and provide definitive care to an even larger number of those discharged into the community. EM clinicians are of...

Background: The availability of patient outcomes-based feedback is limited in episodic care environments such as the emergency department. Emergency medicine (EM) clinicians set care trajectories for a majority of hospitalized patients and provide definitive care to an even larger number of those discharged into the community. EM clinicians are of...

Background: Physical distancing among healthcare workers (HCWs) is an essential strategy in preventing HCW-to-HCWs transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2). Objective: To understand barriers to physical distancing among HCWs on an inpatient unit and identify strategies for improvement. Design: Qualitative study...

Medication safety during care transitions is a significant challenge, especially for older adults prescribed multiple medications. Using a systems approach to understand barriers to and strategies for safe medication management throughout high-risk periods of hospital-to-home transition is one important step in designing effective interventions. Fr...

In a qualitative study of healthcare workers and patients discharged on oral antibiotics, we identified 5 barriers to antibiotic decision making at hospital discharge: clinician perceptions of patient expectations, diagnostic uncertainty, attending physician–led versus multidisciplinary team culture, not accounting for total antibiotic duration, an...

One anesthesia provider is often responsible for prescribing, formulating, dispensing, administering, and documenting medications in the operating room. Unlike other hospital units, there are few safety interventions. Systems engineering approaches can provide important insights into improving patient safety during medication delivery processes (Ka...

Objective To test the feasibility of targeted gown and glove use by healthcare personnel caring for high-risk nursing-home residents to prevent Staphylococcus aureus acquisition in short-stay residents. Design Uncontrolled clinical trial. Setting This study was conducted in 2 community-based nursing homes in Maryland. Participants The study incl...

The COVID-19 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scar...

Introduction: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these c...

Objectives: The patient-centered medical home (PCMH) may provide a key model for ambulatory patient safety. Our objective was to explore which PCMH and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture. Methods: This was a cross-case analysis study in 25 diverse U.S. PCMHs....

We worked with patients, caregivers, and healthcare workers to prioritize barriers and propose solutions to outpatient parenteral antimicrobial therapy (OPAT) care. Unclear communication channels, rushed instruction, safe bathing with an intravenous catheter, and lack of standardized instructions were highly ranked barriers. Outpatient parenteral a...

Hospital-based care of pediatric trauma patients includes transitions between units that are critical for quality of care and patient safety. Using a macroergonomics approach, we identify work system barriers and facilitators in care transitions. We interviewed eighteen healthcare professionals involved in transitions from emergency department (ED)...

A novel coronavirus disease, named coronavirus disease 2019 or COVID-19, which sparked an outbreak in Wuhan, China in December 2019, is now a pandemic. The rapid spread of this disease from one to more than 155 regions worldwide in 2.5 months highlights the need for better preparation to manage a pandemic. In this commentary, we describe how Human...

Inpatient care of pediatric trauma patients includes care transitions, including from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU, which are important to patient safety and quality of care. Previous research identified work system barriers and facilitators in these transitions; the mos...

Objective: To systematically assess safety risks pertaining to tracheostomy care in the long-term care (LTC) setting using a human factors engineering approach. Design: We utilized a 5-part approach to complete our proactive risk assessment: (1) performed a hierarchical task analysis of the processes of tracheostomy stoma and suctioning; (2) ide...

Background Improved antibiotic decision-making during the hospital-to-home transition is an important but under-addressed target for antimicrobial stewardship. This study aims to provide a healthcare worker-informed approach to characterize prescriber antibiotic decision-making and patient medication management at discharge to identify barriers to...

Importance Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life. Objective To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers ca...

Background: More than 28 000 people were infected with Ebola virus during the 2014-2015 West African outbreak, resulting in more than 11 000 deaths. Better methods are needed to reduce the risk of self-contamination while doffing personal protective equipment (PPE) to prevent pathogen transmission. Methods: A set of interventions based on previo...

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering methods, we combine interview, archival document, and trauma regis...

Background: Complicated medical therapies traditionally performed in acute care hospitals are increasingly moving to the home, requiring patients and informal caregivers to perform complicated medical tasks. For example, in outpatient parenteral antimicrobial therapy (OPAT), patients and caregivers perform antimicrobial infusions and venous cathet...

We compared the fluorescent gel removal rate using fewer high-touch surfaces (HTSs) and rooms and determined the optimum number of HTSs and rooms needed to ensure accuracy using 2,942 HTSs in 228 rooms on 13 units. Randomly selecting 3 HTS in 2 rooms predicted the optimal removal rate.

There is a growing awareness that risk identification plays an important role in the investigation of actual and potential harm to patients. Although current risk identification methods in healthcare have strengths and limitations, it is an open question whether they have been implemented optimally and how well they have been integrated to provide...

Outpatient parenteral antimicrobial therapy (OPAT) requires patients and caregivers to infuse antimicrobials through venous catheters (VCs) in the home. The objective of this study was to perform a patient-centered goal-directed task analysis to identify what is required for successful completion of OPAT. The authors performed 40 semi-structured pa...

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space, and particul...

Using a pre–post design, this study examined the impact of a multifaceted program to simultaneously improve 3 health care–associated infections and patient safety culture throughout the cardiac surgery service line in 11 hospitals. Interventions included the Comprehensive Unit-based Safety Program to improve safety culture and evidence-based bundle...

Objectives The study sought to identify collaborative electronic health record (EHR) usage patterns for pediatric trauma patients and determine how the usage patterns are related to patient outcomes. Materials and Methods A process mining–based network analysis was applied to EHR metadata and trauma registry data for a cohort of pediatric trauma p...

Objective To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma. Methods We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine...

There are major gaps and barriers for patients and caregivers after hospital discharge to achieve safe medication use. Patients and caregivers are often not ready to take on the responsibility for medication management when transitioned from inpatient care. Current approaches tend to focus on adding isolated strategies. A system thinking can enable...

About 9.2 million children visit the emergency department (ED) in the US annually because of trauma and 20% experience a missed injury. Upon arriving to the hospital, physicians evaluate the child and make the ED disposition decision of whether to admit, operate or discharge. The objective of this study is to report the challenges mentioned by heal...

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Several clinical teams converge to support trauma care in the Emergency Department (ED); the most severe trauma cases often need surgery in the operating room (OR) and/or are admitted to the pediatric intensive care unit (PICU). These care transitions c...

Objective To systematically assess enhanced personal protective equipment (PPE) doffing safety risks. Design We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors-informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of in...

The EHR problem list has the potential to support care coordination among the multidisciplinary care team that cares for pediatric trauma patients. To realize this potential, the need exists to ensure appropriate utilization by formulating acceptable usage and management policy. In this regard, understanding the prevailing utilization pattern is pi...

The emergence and spread of extensively multidrug-resistant organisms is a public health crisis, and long-term care settings have been identified as a reservoir for the cultivation of these organisms. Long-term care settings are now taking on increasingly ill residents with complicated medical problems, indwelling devices, and significant healthcar...

Background Electronic health record (EHR) systems contain large volumes of novel heterogeneous data that can be linked to trauma registry data to enable innovative research not possible with either data source alone. Objective This article describes an approach for linking electronically extracted EHR data to trauma registry data at the institution...

In this systematic evaluation of fluorescent gel markers (FGM) applied to high-touch surfaces with a metered applicator (MA) made for the purpose versus a generic cotton swab (CS), removal rates were 60.5% (476 of 787) for the MA and 64.3% (506 of 787) for the CS. MA-FGM removal interpretation was more consistent, 83% versus 50% not removed, possib...

Importance Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life. Objective To evaluate a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers. Design,...

Background: Outpatient parenteral antimicrobial therapy (OPAT) requires that patients and their caregivers administer antimicrobial medications in the home via venous catheters. Hazards from physical attributes of the home environment may impede safe performance of OPAT tasks. Methods: We performed a qualitative study, including semistructured t...

Background Electronic health record (EHR) systems contain large volumes of novel heterogeneous data that can be linked to trauma registry data to enable innovative research not possible with either data source alone. Objective This article describes an approach for linking electronically extracted EHR data to trauma registry data at the institution...

Objective To establish the validity of sensor-based measures of work processes for predicting perceived mental and physical exertion of critical care nurses. Materials and methods Repeated measures mixed-methods study in a surgical intensive care unit. Wearable and environmental sensors captured work process data. Nurses rated their mental (ME) an...

Supplementary methods for this study. Supplementary Methods A. Supplementary Methods B. Supplementary Methods C. Supplementary Methods D. (DOCX)

Environmental care (EVC) associates are often considered solely responsible for suboptimal cleaning of patient rooms. Thus, performance improvement efforts have focused on EVC monitoring and training. Little attention, however, has been paid to the large work system that may impede the performance (e.g., completeness of cleaning, efficiency) and we...