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Analysis of General Event Types and Contributing Factors in Patient Safety System Data 患者安全系统数据中一般事件类型及影响因素分析
A. Tabaie, A. Fong
Patient safety event reporting systems (PSRS) aim to identify safety hazards by encouraging hospital staff to report adverse events, errors, and potential errors in the healthcare system. PSRS collect different information regarding a safety event such as contributing factors and general event types. Users select contributing factors and general event types of a safety incident from predefined lists; therefore, most frequent general event types and contributing factors are commonly recorded together. Contributing factors are often related to the leading cause of an unsafe condition; therefore, identifying contributing factors can help with detecting and mitigating safety issues. In this study, we identified the general event types and contributing factors which were frequently recorded together. We calculated point-wise mutual information (PMI) between each pair to find the association between a contributing factor and a general event type. Our analysis demonstrated strong association between general event type and contributing factors which were most frequently recorded together. Fall and lost/impaired balance (PMI=15.12), skin/tissue and friction/shear (PMI=14.32), and blood bank and patient/sample incorrectly identified (PMI=13.78) were the three pairs of general event type and contributing factors which presented strong association.
患者安全事件报告系统(PSRS)旨在通过鼓励医院工作人员报告医疗系统中的不良事件、错误和潜在错误来识别安全隐患。PSRS收集有关安全事件的不同信息,如促成因素和一般事件类型。用户从预定义列表中选择安全事件的促成因素和一般事件类型;因此,最常见的一般事件类型和促成因素通常被记录在一起。促成因素往往与不安全状况的主要原因有关;因此,识别促成因素有助于发现和缓解安全问题。在这项研究中,我们确定了经常一起记录的一般事件类型和促成因素。我们计算了每对之间的逐点互信息(PMI),以找到促成因素和一般事件类型之间的关联。我们的分析表明,一般事件类型和最频繁记录在一起的促成因素之间有很强的相关性。跌倒和平衡丧失/受损(PMI=15.12)、皮肤/组织和摩擦/剪切(PMI=14.32)以及血库和患者/样本识别错误(PMI=13.78)是三对表现出强烈关联的一般事件类型和促成因素。
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引用次数: 0
Modeling and simulation for situation awareness distribution and transactions for intrahospital patient transports 医院内患者运输的态势感知分布和事务建模与仿真
Abdulrahman A Alhaider, Nathan Lau, Paul B. Davenport, Stimis R. Smith, Darrell W. DeWeese
Intrahospital transports rely on effective transmission of information between medical staff and information systems to support Distributed Situation Awareness (DSA) on patient status and transport requirements. This study presents the preliminary results a simulation model combining discrete event simulation (DES) and agent-based modeling (ABM) to quantify SA distribution and transactions for intrahospital transportation. The simulation model captured the transport requests, transport processes, and knowledge distribution and transactions between (human or machine) agents for intrahospital transports. Specifically, this paper presents the simulation results for the successful patient transport from 17 hospital inpatient units to the radiology department for (1) transport times and (2) transport cancellations. One-way t-tests did not reveal any significant differences in average transport time and number of cancelations between outputs of 100 simulation replications and historical data for 18-month operation. These results indicate that the simulation model represents real-world operation that can subsequently be used to test potential intervention to improve DSA in patient flow.
院内运输依赖于医务人员和信息系统之间的有效信息传输,以支持对患者状态和运输要求的分布式态势感知(DSA)。本研究提供了一个结合离散事件模拟(DES)和基于代理的建模(ABM)的模拟模型的初步结果,以量化医院内运输的SA分布和交易。模拟模型捕捉了医院内部运输的运输请求、运输过程以及(人或机器)代理之间的知识分配和交易。具体而言,本文给出了从17个医院住院单元到放射科的成功患者运输的模拟结果,包括(1)运输时间和(2)运输取消。单向t检验未显示100次模拟复制的输出与18个月操作的历史数据之间的平均传输时间和取消次数有任何显著差异。这些结果表明,模拟模型代表了真实世界的操作,随后可用于测试潜在的干预措施,以改善患者流中的DSA。
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引用次数: 0
The Critical Role of Developmental Psychology in Addressing Generational Stereotypes Associated With Use of Digital Health Technologies 发展心理学在解决与使用数字健康技术相关的代际刻板印象方面的关键作用
M. K. Smith, Margaret Dowst, Laura Thomson Farm
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引用次数: 0
Lessons Learned Using Rapid Human Factors Methods: Condensed Timeline with Effective and Impactful Results 使用快速人为因素方法的经验教训:具有有效和有影响力结果的压缩时间线
Kyle D. Maddox, Deborah Ercolini, N. Chumbler, Tim Arnold, Kathleen Adams, Helen J. A. Fuller
Contextual inquiry and discount usability represent a powerful combination of human factors methods as a responsive and rapid approach to better understand end users’ interactions with a new electronic health record (EHR) system as an enterprise capability. Contextual inquiry is an approach to conducting ethnographic field studies and discount usability is a simplified and efficient technique to identify usability issues. This paper describes how the Veterans Health Administration (VHA) Office of Health Informatics Human Factors Engineering (OHI HFE) responded to a request from VHA leadership to provide rapid support to assess EHR post-implementation system performance to discover if there are barriers or shortcomings. The team utilized contextual inquiry methods and principles of discount usability to assess system usability and effectiveness in meeting end-user needs. OHI and the Electronic Health Record Modernization Integration Office (OEHRM IO) formed a team to conduct semi-structured interviews and observations with health care providers at a VHA facility to gather qualitative data showcasing representative users’ experiences with the EHR. The team analyzed the data collected to identify themes and created an affinity map and two service blueprints. It then used this information to produce a report of findings and recommendations. The study identified areas that required remediation, actions that would facilitate success, and opportunities for improvement. Key contributors to the success of this rapid and important effort included the team’s ability to accommodate a compressed schedule by carefully targeting scope; focusing on a smaller number of participants than originally planned; asking direct, targeted questions developed in advance; and capturing data during short interview and observation windows. The data collected also highlights opportunities to continue the use of discount usability methods, when necessary, to continuously improve OHI HFE data collection and achieve targeted quality improvement in a condensed timeframe.
上下文查询和折扣可用性代表了人为因素方法的强大组合,作为一种响应迅速的方法,可以更好地理解最终用户与作为企业功能的新电子健康记录(EHR)系统的交互。语境调查是进行人种学实地研究的一种方法,而折扣可用性是一种简化而有效的识别可用性问题的技术。本文描述了退伍军人健康管理局(VHA)健康信息人因工程办公室(OHI HFE)如何响应VHA领导层的请求,为评估EHR实施后系统的性能提供快速支持,以发现是否存在障碍或缺点。团队利用上下文查询方法和折扣可用性原则来评估系统的可用性和有效性,以满足最终用户的需求。OHI和电子健康档案现代化整合办公室(OEHRM IO)组成了一个小组,与VHA设施的医疗保健提供者进行半结构化访谈和观察,以收集定性数据,展示有代表性的用户使用电子健康档案的经验。该团队分析了收集的数据以确定主题,并创建了一个关联图和两个服务蓝图。然后,它利用这些信息编制了一份调查结果和建议报告。该研究确定了需要补救的领域,将促进成功的行动,以及改进的机会。这一快速而重要的工作取得成功的关键因素包括团队通过仔细定位范围来适应压缩时间表的能力;专注于比原计划更少的参与者;提前提出直接、有针对性的问题;并在短暂的采访和观察期间获取数据。收集的数据还突出了继续使用折扣可用性方法的机会,必要时,持续改进OHI HFE数据收集,并在压缩的时间框架内实现目标质量改进。
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引用次数: 0
Identification of Known Use-Related Problems in Artificial Intelligence Medical Imaging Devices 人工智能医疗成像设备中已知使用相关问题的识别
Yuhao Chen, Shihui Ruan, K. Plant, Shimeng Du
As Artificial Intelligence (AI) advances, it is included into more and more medical device systems to carry out these systems’ intended functions. Given AI’s ability to learn from real-world use and its capability to continuously improve performance, manufacturers of medical devices are utilizing AI to innovate their products to better assist health care providers. However, like application of other types of medical devices, the application of AI in medical care might pose different types of potential risks to the patients, the users themselves, and to the use environment. For manufactures to successfully ensure the safety of AI medical devices, it is crucial to identify known problems by investigating use-related, user interface, and user interaction in-cidents that have occurred in comparable medical devices. The objective of this study is to identify potential use-related problems of DeepView® Wound Imaging System that assesses the healing potential of thermal burn wounds by analyzing multispectral images with an ML algorithm. We use a variety of sources of information on reports and recalls of medical devices that are associated with deaths, serious injuries and mal-functions. After examining relevant reports and recalls, 19 use-related problems were identified. An in-depth analysis was then conducted, considering each identified use-related problem and determining how it relates to the specific features and functionality of DeepView® Wound Imaging System as well as identifying patterns and commonalities among them. The information gained from this analysis can be beneficial in enhancing the safety of AI medical devices by providing a deeper understanding of the reasons for failure, to avoid similar issues in the future, and ultimately to improve patient safety and public health.
随着人工智能的发展,它被纳入越来越多的医疗设备系统,以实现这些系统的预期功能。鉴于人工智能从现实世界中学习的能力及其不断提高性能的能力,医疗设备制造商正在利用人工智能创新其产品,以更好地帮助医疗保健提供者。然而,与其他类型医疗设备的应用一样,人工智能在医疗保健中的应用可能会对患者、用户本身和使用环境带来不同类型的潜在风险。对于制造商来说,要成功确保人工智能医疗设备的安全,通过调查类似医疗设备中发生的与使用相关的、用户界面和用户交互来识别已知问题至关重要。本研究的目的是确定DeepView®伤口成像系统的潜在使用相关问题,该系统通过使用ML算法分析多光谱图像来评估热烧伤伤口的愈合潜力。我们使用各种信息来源来报告和召回与死亡、严重伤害和功能失常有关的医疗器械。在审查了相关报告和召回后,发现了19个与使用有关的问题。然后进行了深入分析,考虑了每个已确定的与使用相关的问题,确定了它与DeepView®伤口成像系统的特定特征和功能之间的关系,并确定了它们之间的模式和共性。从这一分析中获得的信息有助于提高人工智能医疗设备的安全性,因为它可以更深入地了解失败的原因,避免未来出现类似问题,并最终改善患者安全和公共健康。
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引用次数: 0
Let’s pause for a second: Neurodynamic evidence for rapid and coordinated team pauses during simulated patient encounters 让我们暂停一下:神经动力学证据表明,在模拟病人接触过程中,快速和协调的团队暂停
Ronald H. Stevens, Trysha Galloway
In this study we explored neurodynamic candidates for coordinated periods of wakeful rest across team members while they performed healthcare simulations. Wakeful rest occurs sporadically when a person pauses task-related behavior at goal areas or choice points and is thought to be associated with memory replay. Analysis of the second-by-second EEG-derived neurodynamics of Emergency Medical Flight dyads identified periods of inter-brain coordination that surrounded periods of individual team member uncertainty but were negatively correlated with them (r = -.3 to - .81). The brain region expression and inter-brain network connectivity of the shared information had properties consistent with the default mode network (DMN), an important effector of wakeful rest in animals and humans. This shared information was present in the 70-110 Hz electroencephalogram (EEG) spectrum which may represent bursts of memory replay. Going forward, our hypothesis is that these periods of wakeful rest (pauses) associated with increased inter-brain coordination may represent self-imposed or opportunistic ‘time-outs’ for team members to ‘gather their thoughts’ and mentally replay recent events before mentally projecting their plans forward.
在这项研究中,我们探索了团队成员在进行医疗模拟时协调清醒休息时期的神经动力学候选者。当一个人在目标区域或选择点暂停与任务相关的行为时,偶尔会出现清醒休息,这被认为与记忆回放有关。对紧急医疗飞行双组的逐秒脑电图神经动力学的分析发现,大脑间协调的时期围绕着团队成员个体不确定的时期,但与他们呈负相关(r = -)。3到- 0.81)。共享信息的脑区表达和脑间网络连通性与动物和人类清醒休息的重要效应物默认模式网络(DMN)具有一致的特性。这种共享信息出现在70-110赫兹脑电图(EEG)频谱中,这可能代表记忆重放的爆发。展望未来,我们的假设是,这些与大脑间协调能力增强相关的清醒休息(暂停)可能代表了团队成员自我强加的或机会主义的“暂停”,以便“收集他们的想法”,并在精神上重播最近的事件,然后再在精神上预测他们的计划。
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引用次数: 0
Applications of Extended Reality (XR) in obtaining informed consent: A narrative review 扩展现实(XR)在获取知情同意中的应用:叙述性回顾
Michelle M. Y. Lai, Rob (Hongbo) Chen, Andrew Evanyshyn, Zeina Shaltout, Myrtede C. Alfred
Informed consent in healthcare requires patients to have a sufficient understanding of their upcoming procedure before deciding to proceed. Unfortunately, education prior to a surgical procedure is constrained by barriers including poor health literacy, language barriers, one-sided dialogue during consultations, anxiety, and knowledge retention. Extended reality (XR), which includes virtual reality (VR), augmented reality (AR), and mixed reality (MR) has the potential to improve informed consent processes by creating an immersive, interactive, and multimodal sensory experience that supports patient education. The purpose of the study was to review the extant literature on the effectiveness of XR technology in improving patient education, a vital component of informed consent. We screened fifty-two articles and ten relevant papers from PubMed, Scopus, and Compendex, which were included in the review based on our eligibility criteria. We found that VR and AR proved effective in enhancing patient education in eight studies, and thus improving informed consent processes. MR was not utilized in the studies reviewed. The studies were conducted in several countries and positives findings were reported from a broad range of clinical settings and procedures. Though further investigation is needed, this is a promising finding that may encourage health systems to implement similar interventions prior to procedures. The review also provided an overview of the existing XR technology utilized for patient education such as a downloadable mobile application with a virtual chatbot character, and an environment designed to simulate the MRI patient’s perspective. These applications provide immersive and interactive experiences when paired with a head mounted headset such as Google VR Cardboard. The findings also revealed that XR tools are customizable and can be tailored to specific surgical procedures, which makes the potential of implementation applicable to a broader range of settings.
医疗保健中的知情同意要求患者在决定进行之前对即将进行的手术有充分的了解。不幸的是,手术前的教育受到各种障碍的限制,包括卫生知识贫乏、语言障碍、会诊时的单方面对话、焦虑和知识保留。包括虚拟现实(VR)、增强现实(AR)和混合现实(MR)在内的扩展现实(XR)有可能通过创建支持患者教育的沉浸式、交互式和多模态感官体验来改善知情同意流程。这项研究的目的是回顾现有的关于XR技术在改善患者教育方面的有效性的文献,这是知情同意的重要组成部分。我们从PubMed、Scopus和Compendex中筛选了52篇文章和10篇相关论文,根据我们的资格标准纳入了综述。我们发现VR和AR在八项研究中被证明有效地加强了患者教育,从而改善了知情同意过程。在回顾的研究中没有使用MR。这些研究是在几个国家进行的,从广泛的临床环境和程序中报告了阳性结果。虽然需要进一步调查,但这是一个有希望的发现,可能会鼓励卫生系统在手术前实施类似的干预措施。该综述还概述了用于患者教育的现有XR技术,例如具有虚拟聊天机器人特征的可下载移动应用程序,以及旨在模拟MRI患者视角的环境。当与谷歌VR Cardboard等头戴式耳机配对时,这些应用程序提供身临其境的互动体验。研究结果还显示,XR工具是可定制的,可以针对特定的外科手术进行定制,这使得实施的潜力适用于更广泛的环境。
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引用次数: 0
Best Practices for Use-Related Risk Analysis Through Collaboration of Human Factors and Clinical 通过人为因素和临床协作进行使用相关风险分析的最佳实践
H. M. Mehrzad, T. Stüdeli, Helene Quie
Integrating the human factors engineering (HFE) process, and its user-centered approach, into the medical device and combination Product and Development Process (PDP), has been an ongoing challenge for its respective industries and Human Factors (HF) practitioners within it for decades. Yet, despite continuous process adaptation and evolution of the HFE process, as well as the introduction of standards and health authority guidelines, the early integration of a risk-based and user-centered approach within the development and design process remains an ongoing practical challenge occupying the minds of most. With the introduction of the European MDR 2017/745 in 2017, an additional emphasis was put on the importance of use-related risk identification, assessment, and data based evaluation within the clinical evaluation process, and with such introduces clinical teams to (new) ‘use-related risk challenges’ as well. This paper provides a framework for early integration of an iterative use-related risk analysis approach, addressing common practical challenges, and providing best practices for such. Furthermore, it highlights how applying a collaborative approach between HF and clinical efforts would permit for collection of more robust use-related data sets, thus potentially optimizing use-related risk, residual risk, and risk-benefit analyses and their processes.
几十年来,将人因工程(HFE)过程及其以用户为中心的方法集成到医疗设备和组合产品与开发过程(PDP)中,一直是其各自行业和其中的人因(HF)从业者面临的持续挑战。然而,尽管HFE过程不断进行过程调整和演变,并引入了标准和卫生当局指南,但在开发和设计过程中尽早整合基于风险和以用户为中心的方法仍然是大多数人心中持续存在的实际挑战。随着2017年欧洲MDR 2017/745的推出,在临床评估过程中,进一步强调了使用相关风险识别、评估和基于数据的评估的重要性,并向临床团队介绍了(新的)“使用相关风险挑战”。本文为迭代使用相关风险分析方法的早期集成提供了一个框架,解决了常见的实际挑战,并为此提供了最佳实践。此外,它强调了在HF和临床工作之间应用协作方法将如何允许收集更稳健的与使用相关的数据集,从而潜在地优化与使用相关风险、剩余风险和风险收益分析及其过程。
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引用次数: 0
Cracking The Code: Redesigning EHR Interfaces to Clarify Patients’ End of Life Wishes for Code Situations 破解密码:重新设计EHR接口,明确患者对密码情况的临终愿望
Sony Mani, M. Jamil
Across various healthcare systems, serious patient safety issues occur where patients who express Do-Not-Resuscitate (DNR) wishes receive resuscitative measures in error. Our Patient Safety team conducted a common cause analysis and identified contributing factors to such errors, including the unclear display of patients’ code status in the electronic health record (EHR). Our team proposed updated wording for the code status in the EHR and evaluated the proposed design via remote usability testing. Eleven physician and nurse end users participated in 30-minute one-on-one sessions where they consulted EHR screens to respond to simulated patient emergency scenarios. All participants successfully interpreted the updated screens and responded positively to the changes. Following these results, a multidisciplinary team used a Failure Modes and Effects Analysis (FMEA) to guide the successful implementation of the updated design.
在各种医疗保健系统中,当表达不复苏(DNR)愿望的患者错误地接受复苏措施时,会发生严重的患者安全问题。我们的患者安全团队进行了常见原因分析,并确定了导致此类错误的因素,包括电子健康记录(EHR)中患者代码状态的不清晰显示。我们的团队建议在EHR中更新代码状态的措辞,并通过远程可用性测试评估建议的设计。11名医生和护士最终用户参加了30分钟的一对一会议,他们在会上咨询电子病历屏幕,以应对模拟的患者紧急情况。所有参与者都成功地解读了更新后的屏幕,并对这些变化做出了积极的反应。根据这些结果,一个多学科团队使用失效模式和影响分析(FMEA)来指导更新设计的成功实施。
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引用次数: 0
Considering Team Dynamics during Human Factors Work in Healthcare 考虑医疗保健中人因工作中的团队动力学
Helen J. A. Fuller, Kyle D. Maddox, Kathleen Adams, Tim Arnold
A significant body of human factors (HF) work has focused on how people collaborate on teams in various operational settings such as aviation and nuclear power. Less work, however, has focused on the team dynamics of groups conducting HF studies. This paper describes a collaborative effort led by HF practitioners to understand and document user needs and challenges associated with the adoption of a new electronic health record (EHR) at a medical facility. By examining the challenges and opportunities presented by the interdisciplinary nature of the team, we can identify best practices for future study and change management efforts that may ultimately lead to greater organizational maturity and the development of better, safer systems.
大量的人为因素(HF)工作集中在人们如何在各种操作环境(如航空和核电)中进行团队协作。然而,较少的工作集中在进行心衰研究的团队动态上。本文描述了由心衰从业者领导的协作努力,以了解和记录与医疗机构采用新的电子健康记录(EHR)相关的用户需求和挑战。通过检查团队的跨学科性质所呈现的挑战和机会,我们可以确定未来研究和变更管理工作的最佳实践,这些工作可能最终导致更大的组织成熟度和更好、更安全系统的开发。
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引用次数: 0
期刊
Proceedings of the International Symposium of Human Factors and Ergonomics in Healthcare. International Symposium of Human Factors and Ergonomics in Healthcare
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