Human Factors–Focused Reporting System for Improving Care Quality and Safety in Hospital Wards

Morag, Ido; Gopher, Daniel; Spillinger, Avishag; Auerbach-Shpak, Yael; Laufer, Neri; Lavy, Yuval; Milwidsky, Ariel; Feigin, R D; Pollack, Shimon; Maza, Itay; Azzam, Zaher S.; Admi, Hanna; Soudry, Michael

doi:10.1177/0018720811434767

Cited by 14 publications

(9 citation statements)

References 22 publications

(25 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…In comparison to other industries, hospitals must still improve on identification, analysis, evaluation, and control of crises within hospital facilities [ 16 , 17 ]. The literature research shows that an effective defence against crises is only possible if the capacity to handle them becomes a more important part of the hospitals’ organizational culture [ 18 , 19 ]. This is why the transition to a crisis resolution culture is recommended.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Human resource crises in German hospitals—an explorative study

et al. 2015

View full text Add to dashboard Cite

BackgroundThe complexity of providing medical care in a high-tech environment with a highly specialized, limited labour force makes hospitals more crisis-prone than other industries. An effective defence against crises is only possible if the organizational resilience and the capacity to handle crises become part of the hospitals’ organizational culture. To become more resilient to crises, a raised awareness—especially in the area of human resource (HR)—is necessary. The aim of this paper is to contribute to the process robustness against crises through the identification and evaluation of relevant HR crises and their causations in hospitals.MethodsQualitative and quantitative methods were combined to identify and evaluate crises in hospitals in the HR sector. A structured workshop with experts was conducted to identify HR crises and their descriptions, as well as causes and consequences for patients and hospitals. To evaluate the findings, an online survey was carried out to rate the occurrence (past, future) and dangerousness of each crisis.ResultsSix HR crises were identified in this study: staff shortages, acute loss of personnel following a pandemic, damage to reputation, insufficient communication during restructuring, bullying, and misuse of drugs. The highest occurrence probability in the future was seen in staff shortages, followed by acute loss of personnel following a pandemic. Staff shortages, damage to reputation, and acute loss of personnel following a pandemic were seen as the most dangerous crises.ConclusionsThe study concludes that coping with HR crises in hospitals is existential for hospitals and requires increased awareness. The six HR crises identified occurred regularly in German hospitals in the past, and their occurrence probability for the future was rated as high.

show abstract

Section: Introductionmentioning

confidence: 99%

“…This is why the transition to a crisis resolution culture is recommended. To become more resilient to crises, a raised awareness of crises, especially in the area of HR, is necessary [ 19 ].…”

Section: Introductionmentioning

confidence: 99%

Human resource crises in German hospitals—an explorative study

et al. 2015

View full text Add to dashboard Cite

show abstract

“…Benner et al 2002). However, adverse events are often under-reported (Husch et al 2005;Morag et al 2012), while the reports themselves often lack the necessary detail to establish why the error occurred (Nemeth et al 2009a, b). In addition, Dekker (2007) argues that error counting systems ''uphold an illusion of rationality and control but may offer neither real insight nor productive routes for improving safety''.…”

Section: Introductionmentioning

confidence: 99%

“…However, within the context of healthcare, focus has been less on mismatch between user and device and more on mismatches between different people's mental models; e.g. Morag et al (2012) examined differences between the mental models of physicians and nurses on a gynaecology ward. While mismatches between people's mental models of work processes can lead to difficulties and failures, there is a need to also consider how the technology used within a ward environment may also contribute to error when there is a mismatch between user and device.…”

Section: Introductionmentioning

confidence: 99%

How external and internal resources influence user action: the case of infusion devices

et al. 2016

View full text Add to dashboard Cite

Human error can have potentially devastating consequences in contexts such as healthcare, but there is a rarely a simple dichotomy between errors and correct behaviour. Furthermore, there has been little consideration of how the activities of users (erroneous and otherwise) relate to the conceptual fit between user and device, despite the fact that healthcare technologies are becoming increasingly prevalent and complex. In this article, we present a study in which nurses' conceptions of infusion device practice were elicited to identify misfits. By focusing on key concepts that users work with when setting up infusions and the extent to which the system supports them, our analysis highlights how actions are influenced by the different resources available to users including: the device itself; supporting artefacts; the conceptual understanding of the user; and the community of practice the user is part of. The findings reveal the ways in which users are resourceful in their day-to-day activities and also suggest potential vulnerabilities within the wider system that could threaten patient safety. Our approach is able to make previously under-explored aspects of practice visible, thus enabling insight into how users act and why.

show abstract

“…Interventions to reduce the impact of human failures in the healthcare practice had been vigorously studied [8-10], including Team Resources Management (TRM) and TeamSTEPPS [2,5,9,10]. These programs and tools derived from aviation safety and crew training experiences [11,12], and focused on a number of training components for knowledge, skills and attitude, such as leadership, situation awareness, mutual support and communication [9,13], and have been deemed promising in enhancing patient safety in the healthcare settings.…”

Section: Introductionmentioning

confidence: 99%

Integrating team resource management program into staff training improves staff’s perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan

et al. 2014

View full text Add to dashboard Cite

BackgroundThe process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process.MethodsWe implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes.ResultsDuring the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records.ConclusionImplementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.

show abstract

Human Factors–Focused Reporting System for Improving Care Quality and Safety in Hospital Wards

Abstract: This type of reporting system could fill an important information gap with the potential to be a cost-effective initial database source to guide human factors efforts to improve care quality, reduce errors, and increase patient safety.

Cited by 14 publications

References 22 publications

Human resource crises in German hospitals—an explorative study

Human resource crises in German hospitals—an explorative study

How external and internal resources influence user action: the case of infusion devices

Integrating team resource management program into staff training improves staff’s perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan

Contact Info

Product

Resources

About