Sara Albolino

• PhD Social Sciences
• Executive at Umberto I Policlinico di Roma

Human Factors and Ergonomics (HFE) theory and methodology is well established in many industries. In healthcare it is still in its infancy and not well established, despite increasing evidence of the need to implement a HFE approach in day to day operations.

Italy was the first country after China to be affected by COVID-19. The wave of the emergency found our country unprepared to cope with the surge of patients going to first aid departments to seek assistance in the almost complete paralysis of community health. Human factors and ergonomics (HFE) can effectively contribute to, and improve the effect...

Since the publication of the 1999 IOM report “To Err Is Human: Building a Safer Health System,” much has been learned about pediatric patient safety. However, adverse events still affect one-third of all hospitalized children [1]. The main areas of adverse events are hospital-acquired infections, intravenous line complications, surgical complicatio...

The increasing complexity and dynamicity of our society (and world of work) have meant that healthcare systems have and continue to change and consequently the state of healthcare systems continues to assume different characteristics. The causes of mortality are an excellent example of this rapid transformation: non-communicable diseases have becom...

Background The dissemination of scientific data on coronavirus disease 2019 (COVID-19) continually builds but, in April 2020, could not keep up with the spread of the disease. Through technology, surgeons in Italy and the UK, representing both peak and pre-peak infective time zones, were able to communicate so that the urgent lessons on the huge ex...

Patient suicide is one of the most frequent incidents in healthcare facilities to be reported to the National Observatory of Sentinel Events in Italy. Despite national initiatives, in Tuscany potentially preventable patient suicides still occur in both acute and community care settings. We describe here an aggregated qualitative analysis of 14 pati...

Introduction: Falls in hospitals are a major problem also in pediatric settings. No Pediatric Fall Risk Assessment Scales (PFRAS) are validated in Italian. Goals: to perform the Italian validation of the Humpty-Dumpty Falls Scale (HDFS); to assess its predictive performance; to estimate the frequency of falls in hospitalized children and to anal...

Several of the key organizational issues that we have had to face with the emergence of COVID-19 crisis are related to Human Factors/Ergonomics (HFE) and the safety culture. During the crisis the main activities of the healthcare services have been profoundly affected. Patient safety and risk management units have also experienced the need to adapt...

Objectives: Thirteen suspicious deaths occurred in an intensive care unit of Tuscany, Italy, in 2015. All patients developed sudden unexplained coagulopathy leading to severe bleeding. None of them had been prescribed heparin, but supertherapeutic concentrations of heparin were found. After a nurse was arrested on suspicion of murdering Human Fact...

Echoing the World Health Organization's (WHO) request, the Patient Safety Declaration, launched by Health First Europe at the European Parliament, calls on policymakers, authorities and health professionals, patients and citizens to come together to build health systems that can help health professionals work better for patient-centred outcomes. Th...

Background: The International Ergonomics Association is a professional association for human factors and ergonomics (HFE) professionals. Australia and New Zealand are two of 52 Federated Societies within the IEA. Objective: This paper describes an Ergonomics and the Future World (EFW) workshop held at the IEA Triennial Congress in 2018 (IEA2018)...

In this paper we elaborate a preliminary framework to fill this gap and describe the potential contributions of HFE to improve digital health interventions, at the macro, meso and micro level of a health system. Researchers present a practical approach, integrated with some limited reflections on methodological aspects, recently covered in a positi...

Communication between health facilities is one of the fundamental elements for a proper management of women during pregnancy and delivery. Failures of the process, mainly due to an absence of a structured handover, are closely associated with adverse events and near misses. This research has two main aims: to assess the presence and characteristics...

The use of tools to support the work of health professionals in managing clinical risk is widespread particularly in high-income countries. In 2008 the WHO designed a checklist for the safety and quality of care during childbirth. A multicentric study has been conducted by the Centre GRC of the Tuscany Region (Italy) with the aim of evaluating the...

Abstract The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems. Over the last t...

Context: Patient safety is a strategic activity in children's care. Epidemiological data and evidences from the literature are less for patient safety in pediatrics and there is a need for comparing experiences and applied solutions of different contexts. Patient Safety in Pediatrics requires lots of specifications comparing to the actions and solu...

The burden of unsafe care is still very high all around the globe. A study conducted in 2012 in African and Middle Eastern Countries reports that in developing countries the incidence of adverse event is 8,2% and of these 83% are preventable. WHO estimates that about 287.000 are maternal deaths, 1 million fetal deaths during intrapartum period and...

Care transitions are critical moments which may expose patients to adverse events and generate organizational failures. Ineffective care transition processes lead to higher hospital readmission rates and costs and patients can be harmed when the many moving parts of their care process are not effectively coordinated.

Epidemiological data from the literature are few for patient safety in pediatrics and there is a need for comparing experiences and applied solutions in different contexts. A study published in 2012 underlined that the 79% of adverse events in children happened in intensive care unit, the incidence on admissions is of 6,5 and 44,7% of these adverse...

Data monitoring and reporting systems are extremely important for safety and quality of care. The use of tools to support the work of health professionals in managing clinical risk is widespread particularly in high income countries. In 2008 the World Health Organization designed a checklist for the safety during childbirth (safe Childbirth Checkli...

This book presents the proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), held on August 26-30, 2018, in Florence, Italy. By highlighting the latest theories and models, as well as cutting-edge technologies and applications, and by combining findings from a range of disciplines including engineering, design, ro...

This book presents the proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), held on August 26-30, 2018, in Florence, Italy. By highlighting the latest theories and models, as well as cutting-edge technologies and applications, and by combining findings from a range of disciplines including engineering, design, ro...

This book presents the proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), held on August 26-30, 2018, in Florence, Italy. By highlighting the latest theories and models, as well as cutting-edge technologies and applications, and by combining findings from a range of disciplines including engineering, design, ro...

This book discusses how digital technology and demographic changes are transforming the patient experience, services, provision, and planning of health and social care. It presents innovative ergonomics research and human factors approaches to improving safety, working conditions and quality of life for both patients and healthcare workers. Persona...

This book presents the proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), held on August 26-30, 2018, in Florence, Italy. By highlighting the latest theories and models, as well as cutting-edge technologies and applications, and by combining findings from a range of disciplines including engineering, design, ro...

This book presents the proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), held on August 26-30, 2018, in Florence, Italy. By highlighting the latest theories and models, as well as cutting-edge technologies and applications, and by combining findings from a range of disciplines including engineering, design, ro...

This book presents the proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), held on August 26-30, 2018, in Florence, Italy. By highlighting the latest theories and models, as well as cutting-edge technologies and applications, and by combining findings from a range of disciplines including engineering, design, ro...

Aim: To develop a systematic approach to detect and prevent clinical risks in complementary medicine (CM) and increase patient safety through the analysis of activities in homeopathy and acupuncture centres in the Tuscan region using a significant event audit (SEA) and failure modes and effects analysis (FMEA). Methods: SEA is the selected tool for...

The aim of this study was to obtain baseline data on doctors’ and nurses’ work activities and rates of interruptions and multi-tasking to improve work organization and processes. Data were collected in six surgical units with the WOMBAT (Work Observation Method by Activity Timing) tool. Results show that doctors and nurses received approximately 13...

The objective of the study is to analyze the variation of adverse events (AEs) according to the different structure of hospitals. The study is a multicenter, retrospective study. It involves 4 teaching hospitals (THs) and 32 community hospitals, distributed in 12 local trusts (LTs), of the Tuscany Regional Healthcare Service (RHS). A random sample...

Maternal and neonatal mortality and morbidity associated with childbirth is a problem of the highest priority. This research has been aimed at testing a modified version of the WHO Safe childbirth checklist in one Italian hospital and to evaluate the tool in terms of its impact on clinical practice and safety. Results show that the presence of corr...

Razionale: La sicurezza delle cure è stata identificata come un elemento strategico dell'attività clinico assistenziale anche in ambito pediatrico. I dati epidemiologici e le evidenze di letteratura sono minori e la necessità di confrontare esperienze esistenti e soluzioni applicate in contesti organizzativi differenti è ancora molto elevata. Numer...

This innovative, comprehensive book covers the key elements of perioperative management of older patients. The book’s chapter structure coincides with the clinical path patients tread during their treatment, from preoperative evaluation to post-hospital care. Epidemiological aspects and aging processes are illustrated, providing keys to understandi...

You can measure opportunity with the same yardstick that measures the risk involved. They go together. Earl Nightingale Introduction From 1999 onwards, after the publication of the report To Err is Human (Kohn et al. 1999), patient safety has become a priority at an international level because “the gulf between a rapidly advancing medical knowledge...

Context: Following the Italian decision to introduce HPV test as primary screening test for screening of the cervical cancer, national authorities and research centers considered necessary to make a proactive analysis of the potential risks of the new screening pathway from the point of view of patient safety. Objectives: The main goal of the proje...

Context: Patient safety is a strategic activity in children's care. Epidemiological data and evidences from the literature are less for patient safety in pediatrics and there is a need for comparing experiences and applied solutions of different contexts. Patient Safety in Pediatrics requires lots of specifications comparing to the actions and solu...

Maternal and neonatal mortality and morbidity associated with childbirth is a global health problem of the highest priority. Of the more than 130 million births each year, the WHO estimates that about 287.000 are maternal deaths, 1 million fetal deaths during intra-partum period and 3 million deaths of infants during the neonatal period. In low- an...

Background:Surgical site infections (SSI) are a serious complication in surgical patients. The incidence of SSI in Europe varies from 9.6% in colon surgery to 0.8% in knee prosthesis. SSI can be prevented through the implementation of simple evidence based strategies. Nevertheless the complexity of health care systems and workplace cultures poses c...

n questo articolo si approfondisce l’analisi di alcuni elementi strategici dei sistemi per la valutazione della sicurezza del paziente, inclusi nei report internazionali e nazionali, con l’obiettivo di fornirne un’analisi critica utile al loro utilizzo per le attività di programmazione e sviluppo delle politiche per la sicurezza del paziente all’in...

The Centre for Patient Safety of the Tuscany Region designs solutions for preventing adverse events in the 39 hospitals and 14 local trusts of the regional healthcare system. One of the most important risks in terms of consequences is the error in blood transfusion. The Centre for Patient Safety adopted an ergonomic approach centered on human facto...

Sono diversi i punti di criticità, potenziale fonte di errori ed eventi avversi nel percorso del paziente che si ricovera in un reparto di medicina interna [1].

Il tema delle buone pratiche, come approccio innovativo alla soluzione di problemi socioeconomici, sta assumendo progressiva rilevanza anche in contesti diversi dalla sanità pubblica.

Background Cross-unit handovers transfer responsibility for the patient among healthcare teams in different clinical units, with missed information, potentially placing patients at risk for adverse events. Objectives We analysed the communications between high-acuity and low-acuity units, their content and social context, and we explored whether co...

To define the incidence of adverse events and their preventability in a representative sample of patients in five acute hospitals located in the North, the Centre and the South of Italy. Other objectives include the evaluation of the consequences of adverse events and their distribution according to specialties. Retrospective and multicentre study....

The vision of HEPS is represented by the bridge connecting the past and future of healthcare services, as well as ergonomists and clinicians, patients and providers. Previous HEPS conferences (Florence 2005 and Strasbourg 2008) successfully contributed to highlight and develop the contribution of ergonomics to patient safety, thanks to the particip...

While the terms ergonomics and human factors have distinctive origins (in Europe, ergonomics referred to the laws of work or how work conditions affect people such as leading to physiological stress or musculoskeletal injury; in the USA, human factors originally focused on the user–system interface or how people interact with equipment, workplaces...

Incident-reporting systems (IRS) are tools that allow front-line healthcare workers to voluntary report adverse events and near misses. The WHO has released guidelines that outline the basic principles on how to design and implement successful IRS in healthcare organisations. A written survey was administered with an assisted self-assessment techni...

In February 2007, three organs from an human immunodeficiency virus (HIV)-positive donor were transplanted at two hospitals in the Tuscany Regional Health Care Service, owing to a chain of errors during the donation process. The heart-beating donor was a 41-year-old woman who died as a result of head trauma. The patient's history did not highlight...

This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, to achieve this result, a change in cultural attitudes is needed. It can be obtained by developing adequate tools for risk analysis, which should focus on the peculiarities of the healthcare systems. A no-blame culture should...

Making sense of circumstances and situations is critical to coordinate cooperative work. Especially in process control domains, we may expect that effective and reliable organizations will possess processes that develop, maintain, distribute, and, when necessary, repair this social understanding (sensemaking). Our research has focused on collective...

This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, for achieving this result, a change in the cultural attitudes is needed. It can be obtained by developing adequate tools for risk analysis which should focus on the peculiarities of the healthcare systems.A no-blame culture sh...

Taylor and Francis(Taylor and Francis), 2005. Quantity pack. Condizione libro: New. 9.685 by 6.85 inches. (587 pages) This item is printed on demand. Please allow up to 10 days extra for printing & delivery. Incorporating the work of an international team of researchers and professionals, this book examines the complex and challenging issues involv...

A number of dimensions are relevant in order to successfully support community life and development. These dimensions include the easiness and broad spectrum of participation, the provision of value in return to the contributions, the visibility of community activity, the support of different levels of membership, the openness to the external world...

Most of the available knowledge management systems pay little attention to two important aspects: the need of supporting emerging communities of interest together with the official organizational structure; and the need of cluing together knowledge associated with any kind of involved entity including people, communities, and informal knowledge. Th...

The paper contains a presentation of the work done in two ESPRIT Projects in the knowledge management area: Klee&Co (Knowledge and Learning Environments for European & Creative Organisations, started in 1998 and ended in 2000) and MILK (Multimedia Interaction for Learning and Knowing, started in early 2002 and expected to be closed by 2004). Klee&C...

Most of the available knowledge management systems pay little attention to two important aspects: the need of supporting emerging communities of interest together with the official organizational structure; and the need of cluing together knowledge associated with any kind of involved entity including people, communities, and informal knowledge. Th...

Most of the available knowledge management systems pay little attention to two important aspects: the need of supporting emerging communities of interest together with the official organizational structure; and the need of cluing together knowledge associated with any kind of involved entity including people, communities, and informal knowledge. Th...

This paper is a critical presentation of the work done by the authors during the past years in two European Projects in the knowledge management area: Klee&Co (Knowledge and Learning Environments for European & Creative Organisations - ESPRIT Program) and MILK (Multimedia Interaction for Learning and Knowing - IST Program). Both projects focus on t...

The paper introduces the experience of the Tuscany Region in building an informative system able to identify risks inside the healthcare local units. It also discusses the related implications on patient safety initiatives. The system basically relies on two main sources of information about clinical risks and accidents inside the hospitals: patien...

The hardest challenge for those who are trying to promote clinical risk management initiatives is cultural change. We need to look at human error in a different way [1]. The experience of risk management in aviation calls for the responsibility of policy makers and stakeholders, those leaders who can set the right climate for incident reporting and...