Background Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.
Background Proper airway management is an essential skill for hospital personnel and rescue services to learn, as it is a priority for the care of patients who are critically ill. It is essential that providers be properly trained and competent in performing endotracheal intubation (ETI), a widely used technique for airway management. Several metrics have been created to measure competence in the ETI procedure. However, there is still a need to improve ETI training and evaluation, including a focus on collaborative research across medical specialties, to establish greater competence-based training and assessments. Training and evaluating ETI should also incorporate modern, evidence-based procedural training methodologies. Objective This study aims to use the cognitive task analysis (CTA) framework to identify the cognitive demands and skills needed to proficiently perform a task, elucidate differences between novice and expert performance, and provide an understanding of the workload associated with a task. The CTA framework was applied to ETI to capture a broad view of task and training requirements from the perspective of multiple medical specialties. Methods A CTA interview was developed based on previous research into the tasks and evaluation methods of ETI. A total of 6 experts from across multiple medical specialties were interviewed to capture the cognitive skills required to complete this task. Interviews were coded for main themes, subthemes in each category, and differences among specialties. These findings were compiled into a skills tree to identify the training needs and cognitive requirements of each task. Results The CTA revealed that consistency in equipment setup and planning, through talk or think-aloud methods, is critical to successfully mastering ETI. These factors allow the providers to avoid errors due to patient characteristics and environmental factors. Variation among specialties derived primarily from the environment in which ETI is performed, subsequent treatment plans, and available resources. Anesthesiology typically represented the most ideal cases with a large potential for training, whereas paramedics faced the greatest number of constraints based on the environment and available equipment. Conclusions Although the skills tree cannot perfectly capture the complexity and detail of all potential cases, it provided insight into the nuanced skills and training techniques used to prepare novices for the variability they may find in practice. Importantly, the CTA identified ways in which challenges faced by novices may be overcome and how this training can be applied to future cases. By making these implicit skills and points of variation explicit, they can be better translated into teachable details. These findings are consistent with previous studies looking at developing improved assessment metrics for ETI and expanding upon their work by delving into methods of feedback and strategies to assist novices.
Social determinants of health (SDOH) and other contextual factors influence a patient’s ability to adhere to a plan of care. Providers must understand these factors in order to develop treatment plans which best meet patient needs and preferences. This is particularly important for patients with type 2 diabetes, which is primarily managed by the patient. Abstraction hierarchy is a modeling technique from the cognitive work analysis framework which describes system components at multiple levels of abstraction. This study seeks to examine SDOH as they relate to type 2 diabetes management by the patient and activities carried out by the primary care provider to incorporate these factors into the medical decision-making process. The abstraction hierarchy was developed based on previous literature and interviews with patients and primary care medical personnel. The resulting abstraction hierarchy can be used to inform future screening tools and patient-centered care interventions for addressing SDOH for patients with type 2 diabetes.
estimated on a per-use basis. This was compared to the purchasing price of Isiris.RESULTS: A total of 1775 cystoscopic procedures were performed, and the reusable cystoscope was used for stent removal in 871 cases. The per-use cost for stent removal procedures using the reusable cystoscope was estimated to be $161.85. The per-use purchasing price for the Isiris device is $200. After 704 stent pulls, micro-costing analysis appears to favor the reusable cystoscope compared to the disposable.CONCLUSIONS: Based on this micro-cost analysis, per-use costs appear to favor the reusable cystoscope for stent removal. It appears that centers with high volumes of stent pulls may find the reusable cystoscope and stent grasper more cost-beneficial than the single-use system. Further study addressing performance and convenience of single-use system is needed.
INTRODUCTION AND OBJECTIVE:There is paucity of data about the hierarchical culture among the operating room (OR) staff. In this study, we aimed to identify how the surgical team's hierarchical relationships affect the frequency and timing (proactive vs. reactive) of risk utterances and their influence on situational awareness in the OR.METHODS: Audio-visual recordings and transcriptions of 10 robot-assisted radical prostatectomies were examined for risk utterances between the surgeon, assistant surgeon, bedside assistant, and scrub nurse. Utterances were classified based on the sender-recipient pair (e.g. surgeon to bedside assistant), their timing (proactive vs. reactive), and the NOTECHS situational awareness score. Proactive utterances were produced with the intent to avoid a problem. Reactive utterances were produced with the intent to correct a problem. Utterances made by the surgeon or assistant surgeon were also classified based on their on-console status. Chisquare tests and ANOVAs were used to determine associations between hierarchical status, utterance timing, on-console status, and NOTECHS scores.RESULTS: Of 4,583 examined utterances, 275 (7%) were riskrelated. Of these, 64% risk utterances occurred from individuals of higher hierarchal status to individuals of lower status (Table 1). Utterances were significantly more reactive than proactive (p < 0.01). Proactive utterances (M [ 2.48) had significantly higher NOTECHS scores than reactive utterances (M [ 1.76) (p < 0.01). 52% of the surgeon and trainee surgeon's utterances were made on-the-console. Utterances were more reactive when on the console and more proactive off the console (p < 0.05). Utterances made by the surgeon or trainee surgeon had significantly higher NOTECHS situational awareness scores when they were off-the-console (M [ 2.42) rather than on (M [ 1.78).CONCLUSIONS: On-console status has the greatest influence on frequency, timing, and rating of risk utterances, rather than the assumed hierarchical status based on traditional surgical practice.
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