Beth Crandall

Problem detection

Problem detection is the process by which people first become concerned that events may be taking an unexpected and undesirable direction that potentially requires action. Previous accounts [e.g., Cowan (Acad Manage Rev 11(4):763–776, 1986)] described problem detection as the accumulation of discrepancies until a threshold was reached. In reviewing incidents taken from a variety of natural settings, we found that discrepancy accumulation did not apply to the incidents we reviewed, because (a) cues to problems may be subtle and context-dependent, and (b) what counts as a discrepancy depends on the problem-solver’s experience and the stance taken in interpreting the situation. In many cases, detecting a problem is equivalent to reconceptualizing the situation.

Critical care physician cognitive task analysis: an exploratory study

IntroductionFor better or worse, the imposition of work-hour limitations on house-staff has imperiled continuity and/or improved decision-making. Regardless, the workflow of every physician team in every academic medical centre has been irrevocably altered. We explored the use of cognitive task analysis (CTA) techniques, most commonly used in other high-stress and time-sensitive environments, to analyse key cognitive activities in critical care medicine. The study objective was to assess the usefulness of CTA as an analytical tool in order that physician cognitive tasks may be understood and redistributed within the work-hour limited medical decision-making teams.MethodsAfter approval from each Institutional Review Board, two intensive care units (ICUs) within major university teaching hospitals served as data collection sites for CTA observations and interviews of critical care providers.ResultsFive broad categories of cognitive activities were identified: pattern recognition; uncertainty management; strategic vs. tactical thinking; team coordination and maintenance of common ground; and creation and transfer of meaning through stories.ConclusionsCTA within the framework of Naturalistic Decision Making is a useful tool to understand the critical care process of decision-making and communication. The separation of strategic and tactical thinking has implications for workflow redesign. Given the global push for work-hour limitations, such workflow redesign is occurring. Further work with CTA techniques will provide important insights toward rational, rather than random, workflow changes.

Relation of repeated low-level blast exposure with symptomology similar to concussion.

Objective:To investigate anecdotal reports suggesting that repeated exposure to low-level explosive blast has myriad health impacts, including an array of neurological effects. Participants:A total of 184 anonymous survey respondents from military and nonmilitary law enforcement populations (135 exposed to occupational blast and 49 controls). Design:Survey of self-reported history of occupational exposure to repeated low-level blast (breaching blast) and symptomology similar to concussion. Results:Findings suggest that number and severity of symptoms increase with history of chronic blast exposure (F = 18.26, P < .001) and that symptoms can interfere with daily activity (t = 2.60, P = .010). Conclusion:Given the prevalence of repeated exposure to blast among some military and civilian law enforcement occupations, the results of this survey study support a role for blast surveillance programs as well as continued research on health impacts of low-level repeated blast exposure.

Expanding Perspectives on Misdiagnosis

A significant insight to emerge from the review of the diagnostic failure literature by Drs. Berner and Graber is that the gaps in our knowledge far exceed the soundly established areas, particularly if we focus on empirical findings based on real-world work by real physicians. This lack of knowledge about the nature of diagnostic problems seems odd, given the current climate of concern and concentrated effort to address safety issues in healthcare, and especially given the centrality of diagnosis in the minds of practitioners. How is it that our knowledge about diagnosis—historically the most central aspect of clinical practice and one that directs the trajectory of tests, procedures, treatment choices, medications, and interventions—has been so impoverished?

Features of Problem Detection

Problem detection is the process by which people first become concerned that events may be taking an unacceptable direction that may require action. Despite its importance, there is surprisingly little empirical or theoretical literature about the cognitive aspects of problem detection. Drawing on previous cognitive task analysis accounts, 52 incidents involving problem detection were selected. Additional interviews were conducted with wildland firefighters and with surgeons. A description of problem detection was developed that emphasizes the role of expertise in detecting and interpreting the significance of subtle cues, as opposed to passively accumulating deviations from expectancies. Further, problem detection is seen as a process of re-conceptualizing the nature of the situation.

Finding and using technology-specific expertise

Successful technology transfer depends on the skills and knowledge of those who must implement new or rapidly advancing technologies. Often, new systems and technologies are delivered without proper preparation of the intended users. Thorough documentation is only part of the solution-during development, many important and technology-specific lessons are learned. These include problem diagnosis, troubleshooting techniques, and strategies for optimum utilization. Many such skills develop in response to incidents that occur during testing and evaluation and are rarely incorporated into formal documentation or instructional materials. Yet they can make the difference between skilled satisfied users and frustrated non-users.

Barriers and Facilitators of Common Ground in Critical Care Teams

Effective collaboration among multi-disciplinary clinical team members has been recognized as a critical component of safe and high quality patient care. There are a variety of systems and procedures in place; however that can impede collaboration by impairing the teams ability to develop and maintain common ground. The current study was an exploratory effort that included an investigation of collaboration in the critical care environment. Direct observations in two urban Intensive Care Units and Cognitive Task Analysis (CTA) interviews with members of the critical care teams highlighted several factors that can contribute to the breakdown of common ground within the critical care team, as well as strategies that can be used to facilitate and support maintenance of common ground.

Applying Knowledge Engineering to Training and Technology Transfer

“Knowledge engineering” refers to the process of getting rules out of the heads of experts and into expert systems. A broader field include a variety of “low technology” applications. If we think of knowledge as a valued resource, analogous to petroleum, this suggests four aspects of knowledge engineering: (a) locating sources of expertise in organizations; (b) assaying the cost/benefits of engineering the expertise; (c) acquiring the knowledge; and (d) codifying the knowledge. In this paper we discuss knowledge engineering strategies and applications beyond expert systems.

Developing a Cognitive and Communications Tool for Burn Intensive Care Unit Clinicians

BACKGROUND Burn Intensive Care Unit (BICU) work is necessarily complex and depends on clinician actions, resources, and variable patient responses to interventions. Clinicians use large volumes of data that are condensed in time, but separated across resources, to care for patients. Correctly designed health information technology (IT) systems may help clinicians to treat these patients more efficiently, accurately, and reliably. We report on a 3-year project to design and develop an ecologically valid IT system for use in a military BICU. METHODS We use a mixed methods Cognitive Systems Engineering approach for research and development. Observations, interviews, artifact analysis, survey, and thematic analysis methods were used to reveal underlying factors that mold the work environment and affect clinician decisions that may affect patient outcomes. Participatory design and prototyping methods have been used to develop solutions. RESULTS We developed 39 requirements for the IT system and used them to create three use cases to help developers better understand how the system might support clinician work to develop interface prototypes. We also incorporated data mining functions that offer the potential to aid clinicians by recognizing patterns recognition of clinically significant events, such as incipient sepsis. The gaps between information sources and accurate, reliable, and efficient clinical decision that we have identified will enable us to create scenarios to evaluate prototype systems with BICU clinicians, to develop increasingly improved designs, and to measure outcomes. CONCLUSION The link from data to analyses, requirements, prototypes, and their evaluation ensures that the solution will reflect and support work in the BICU as it actually occurs, improving staff efficiency and patient care quality.

A Case Study of Source Triangulation Using Artifacts as Knowledge Elicitation Tools in Healthcare Space Design

The importance of triangulating multiple sources of data in the design of tools, technology, and clinical workspaces has not been explicitly addressed in the applied human factors literature. In this paper, we describe an applied human factors case study in which Cognitive Task Analysis was used to triangulate the needs, goals, and design requirements from various stakeholder groups for the design of a Newborn Intensive Care Unit. To facilitate development of common ground on the design goals, in our interviews, we asked questions about (a) stated design goals to elicit the perspectives of meaning across the user groups and (b) schematic renderings of the proposed space. They served as a way to establish a representative definition of each design goal accounting for the perspectives of all user groups. We found that each role brought a perspective and a level of detail based on his/her role goals and lived experience to the design goals. The goals and tradeoffs illuminated by our approach can only be identified when multiple perspectives are collected. Source triangulation should be pursued as part of standard human factors methods to achieve design and evaluation objectives in the context of complex sociotechnical systems.