Castro GM, Buczkowski L, Hafner JM. The Contribution of Sociotechnical Factors to
Health Information Technology-Related Sentinel Events. Jt Comm J Qual Patient Saf
2016 Feb;42(2):70-6
An understanding of how health information technology (HIT) can contribute to sentinel
events is necessary to learn how to safely implement and use HIT. Castro, Buczkowski,
and Hafner conducted an analysis to explore how HIT may contribute to adverse events
that result in death or severe harm to the patient. They showed that HIT-related events
are primarily associated with the socio-technical dimensions of human-computer interface,
workflow and communication, and clinical content. The authors advocate that improved
identification of HIT-related contributing factors in the context of the socio-technical
dimensions may help software developers, device manufacturers, and end users in healthcare
organizations proactively identify vulnerabilities and hazards, ultimately reducing
the risk of harm to patients.
Horsky J, Ramelson HZ. Development of a cognitive framework of patient record summary
review in the formative phase of user-centered design. J Biomed Inform 2016 Dec;64:147-57
A User-Centered Design (UCD) process increases the usability of products in order
to insure human performance and patient safety. However, this design process is challenging
and tricky. In this report, Horsky and Ramelson describe the initial stage of a UCD
process in which foundational design concepts are formulated. They designed and developed
a functional prototype of an ambulatory electronic health record interface that allows
clinicians to briefly review patient data prior to the office visit. Cognitively-based
studies were performed and results are used to develop a cognitive framework that
subsequently guides the design of a prototype.
Kobayashi L, Gosbee J, Merck D Development and application of a clinical microsystem
simulation methodology for human factors-based research of alarm fatigue HERD 2017
Jul;10(4):91-104
Patient monitoring systems with telemetry features are widespread. However, problems
with the design, implementation, and real-world use of these systems result in alarm
fatigue. Therefore, clinical alarms may be ignored or not noticed causing potential
harmful situations to patient safety. Kobayashi, Gosbee, and Merck developed a clinical
micro-system simulation methodology for alarm fatigue research with a human factors
engineering assessment framework. This novel methodology allows not only the assessment
of systems but also supports experimental research purposes.
Percival J, McGregor C. An Evaluation of Understandability of Patient Journey Models
in Mental Health. JMIR Hum Factors 2016 Jul 28;3(2):e20
Little awareness exists about the challenges of integrating information systems with
clinical practice. Recently some work has focused on process modeling through the
lens of the patient, using patient journey modeling techniques. These models can help
understand the potential consequences of the changes in processes and information
flows due to HIT implementation. Percival and McGregor demonstrated the value of a
relatively new patient journey modeling technique called the Patient Journey Modeling
Architecture when compared with traditional manufacturing-based process modeling tools.
Schnittker R, Schmettow M, Verhoeven F, Schraagen JM. Combining situated Cognitive
Engineering with a novel testing method in a case study comparing two infusion pump
interfaces. Appl Ergon 2016 Jul;55:16-26
Infusion pumps contribute to patient care but several adverse drug events have been
associated to their use. Many of those use-related hazards were related to user-interface
design deficiencies. Design solutions using human factors engineering have proven
to be effective to enhance positive performance outcomes. In this regard, Schnittker,
et al., validated the usability of a new infusion pump interface designed with a situated
Cognitive Engineering approach by comparing it to a reference interface using a novel
testing method. The observed reduction of errors, normative path deviations, task
completion times, and keystrokes demonstrated that this method addresses various shortcomings
of previous testing methods.
