Tosha B. Wetterneck

Human factors systems approach to healthcare quality and patient safety

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.

U.S. physician satisfaction: A systematic review

INTRODUCTION There is concern in the US about the burden and potential ramifications of dissatisfaction among physicians. The purpose of this article is to systematically review the literature on US physician satisfaction. METHODS A MEDLINE search with the medical subject headings (MeSH) phrases: (physicians OR physicians role OR physicians women) AND (job satisfaction OR career satisfaction OR burnout), limited to humans and abstracts, with 1157 abstracts reviewed. After exclusions by 2 independent reviewers, 97 articles were included. Physician type sampled, sample size/response rate, satisfaction type, and satisfaction results were extracted for each study. Satisfaction trends were extracted from those studies with longitudinal or repeated cross sectional design. Variables associated with satisfaction were extracted from those studies that included multivariate analyses. RESULTS Physician satisfaction was relatively stable, with small decreases primarily among primary care physicians (PCPs). The major pertinent mediating factors of satisfaction for hospitalists include both physician factors (age and specialty), and job factors (job demands, job control, collegial support, income, and incentives). CONCLUSIONS The majority of factors associated with satisfaction are modifiable. Tangible recommendations for measuring and diminishing dissatisfaction are given.

Information Chaos in Primary Care: Implications for Physician Performance and Patient Safety

Purpose: The purpose of this article is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda. Methods: We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety. Results: Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, and its consequences, and we discuss possible solutions and suggest a research agenda that may lead to methods to reduce the problem. Conclusions: Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying, and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.

Factors contributing to an increase in duplicate medication order errors after CPOE implementation

OBJECTIVE To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors. DESIGN CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs). MEASUREMENT Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors. RESULTS Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered. CONCLUSIONS Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units

Objective To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process. Methods Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process. Results An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16–24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process. Conclusions Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

Worklife and Satisfaction of Hospitalists: Toward Flourishing Careers

ABSTRACTBACKGROUNDThe number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians.OBJECTIVEDetermine current satisfaction levels among hospitalists.DESIGNSurvey study.METHODSA national random stratified sample of 3,105 potential hospitalists plus 662 hospitalist employees of three multi-state hospitalist companies were administered the Hospital Medicine Physician Worklife Survey. Using 5-point Likert scales, the survey assessed demographic information, global job and specialty satisfaction, and 11 satisfaction domains: workload, compensation, care quality, organizational fairness, autonomy, personal time, organizational climate, and relationships with colleagues, staff, patients, and leader. Relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity were explored.RESULTSThere were 816 hospitalist responses (adjusted response rate, 25.6%). Correcting for oversampling of pediatricians, 33.5% of respondents were women, and 7.4% were pediatricians. Overall, 62.6% of respondents reported high satisfaction (≥4 on a 5-point scale) with their job, and 69.0% with their specialty. Hospitalists were most satisfied with the quality of care they provided and relationships with staff and colleagues. They were least satisfied with organizational climate, autonomy, compensation, and availability of personal time. In adjusted analysis, satisfaction with organizational climate, quality of care provided, organizational fairness, personal time, relationship with leader, compensation, and relationship with patients predicted job satisfaction. Satisfaction with personal time, care quality, patient relationships, staff relationships, and compensation predicted specialty satisfaction. Job burnout symptoms were reported by 29.9% of respondents who were more likely to leave and reduce work effort.CONCLUSIONSHospitalists rate their job and specialty satisfaction highly, but burnout symptoms are common. Hospitalist programs should focus on organizational climate, organizational fairness, personal time, and compensation to improve satisfaction and minimize attrition.

Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit

OBJECTIVE To assess the impact of EHR technology on the work and workflow of ICU physicians and compare time spent by ICU resident and attending physicians on various tasks before and after EHR implementation. DESIGN EHR technology with electronic order management (CPOE, medication administration and pharmacy system) and physician documentation was implemented in October 2007. MEASUREMENT We collected a total of 289 h of observation pre- and post-EHR implementation. We directly observed the work of residents in three ICUs (adult medical/surgical ICU, pediatric ICU and neonatal ICU) and attending physicians in one ICU (adult medical/surgical ICU). RESULTS EHR implementation had an impact on the time distribution of tasks as well as the temporal patterns of tasks. After EHR implementation, both residents and attending physicians spent more of their time on clinical review and documentation (40% and 55% increases, respectively). EHR implementation also affected the frequency of switching between tasks, which increased for residents (from 117 to 154 tasks per hour) but decreased for attendings (from 138 to 106 tasks per hour), and the temporal flow of tasks, in particular around what tasks occurred before and after clinical review and documentation. No changes in the time spent in conversational tasks or the physical care of the patient were observed. CONCLUSIONS The use of EHR technology has a major impact on ICU physician work (e.g., increased time spent on clinical review and documentation) and workflow (e.g., clinical review and documentation becoming the focal point of many other tasks). Further studies should evaluate the impact of changes in physician work on the quality of care provided.

The work of adult and pediatric intensive care unit nurses.

Background:Researchers have used various methods to describe and quantify the work of nurses. Many of these studies were focused on nursing in general care settings; therefore, less is known about the unique work nurses perform in intensive care units (ICUs). Objectives:The aim of this study was to observe adult and pediatric ICU nurses in order to quantify and compare the duration and frequency of nursing tasks across four ICUs as well as within two discrete workflows: nurse handoffs at shift change and patient interdisciplinary rounds. Methods:A behavioral task analysis of adult and pediatric nurses was used to allow unobtrusive, real-time observation. A total of 147 hours of observation were conducted in an adult medical–surgical, a cardiac, a pediatric, and a neonatal ICU at one rural, tertiary care community teaching hospital. Results:Over 75% of ICU nurses’ time was spent on patient care activities. Approximately 50% of this time was spent on direct patient care, over 20% on care coordination, 28% on nonpatient care, and approximately 2% on indirect patient care activities. Variations were observed between units; for example, nurses in the two adult units spent more time using monitors and devices. A high rate and variety of tasks were also observed: Nurses performed about 125 activities per hour, averaging a switch between tasks every 29 seconds. Discussion:This study provides useful information about how nurses spend their time in various ICUs. The methodology can be used in future research to examine changes in work related to, for example, implementation of health information technology.

Macroergonomics in Health Care Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS)

BackgroundUnresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation.MethodsSix U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders.DiscussionAt baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes.Trial registrationClinicaltrials.gov identifier NCT01337063