Journal article
Using human factors engineering to improve patient safety in the cardiovascular operating room
Work (Reading, Mass.), Vol.41(1), pp.1801-1804
2012
DOI: 10.3233/WOR-2012-0388-1801
PMID: 22316975
Abstract
Despite significant medical advances, cardiac surgery remains a high risk procedure. Sub-optimal work system design characteristics can contribute to the risks associated with cardiac surgery. However, hazards due to work system characteristics have not been identified in the cardiovascular operating room (CVOR) in sufficient detail to guide improvement efforts. The purpose of this study was to identify and categorize hazards (anything that has the potential to cause a preventable adverse patient safety event) in the CVOR. An interdisciplinary research team used prospective hazard identification methods including direct observations, contextual inquiry, and photographing to collect data in 5 hospitals for a total 22 cardiac surgeries. We performed thematic analysis of the qualitative data guided by a work system model. 60 categories of hazards such as practice variations, high workload, non-compliance with evidence-based guidelines, not including clinicians' in medical device purchasing decisions were found. Results indicated that hazards are common in cardiac surgery and should be eliminated or mitigated to improve patient safety. To improve patient safety in the CVOR, efforts should focus on creating a culture of safety, increasing compliance with evidence based infection control practices, improving communication and teamwork, and designing better tools and technologies through partnership among all stakeholders.
Details
- Title: Subtitle
- Using human factors engineering to improve patient safety in the cardiovascular operating room
- Creators
- Ayse P Gurses - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA., Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD, USA., Department of Health Policy and Management, Bloomberg School of Public Health, Baltimore, MD, USAElizabeth A Martinez - Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Cambridge, MA, USALaura Bauer - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USAGeorge Kim - Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD, USALisa H Lubomski - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USAJill A Marsteller - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA., Department of Health Policy and Management, Bloomberg School of Public Health, Baltimore, MD, USAPriyadarshini R Pennathur - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USAChris Goeschel - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA., Department of Health Policy and Management, Bloomberg School of Public Health, Baltimore, MD, USA., The Johns Hopkins School of Nursing, Baltimore, MD, USAPeter J Pronovost - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA., Department of Health Policy and Management, Bloomberg School of Public Health, Baltimore, MD, USA., The Johns Hopkins School of Nursing, Baltimore, MD, USADavid Thompson - Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA., The Johns Hopkins School of Nursing, Baltimore, MD, USA
- Resource Type
- Journal article
- Publication Details
- Work (Reading, Mass.), Vol.41(1), pp.1801-1804
- DOI
- 10.3233/WOR-2012-0388-1801
- PMID
- 22316975
- ISSN
- 1051-9815
- eISSN
- 1875-9270
- Language
- English
- Date published
- 2012
- Academic Unit
- Industrial and Systems Engineering; Internal Medicine
- Record Identifier
- 9984064105102771
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