Building and revising adaptive capacity sharing for technical incident response: A case of resilience engineering.

We report an organization's method for recruiting additional, specialized human resources during anomaly handling. The method has been tailored to encourage sharing adaptive capacity across organizational units. As predicted by Woods' theory, this case shows that sharing adaptive capacity allows graceful extensibility that is particularly useful when a system is challenged by frequent but unpredictably severe events. We propose that (1) the ability to borrow adaptive capacity from other units is a hallmark of resilient systems and (2) the deliberate adjustment adaptive capacity sharing is a feature of some forms of resilience engineering. Some features of this domain that may lead to discovery of resilience and promote resilience engineering in other settings, notably hospital emergency rooms.

Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion.

OBJECTIVE: The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE). METHODS: Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical records of FFCDE patients and admission logs from the emergency department (ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis focused on how the ED and other units adapted to coping with the difficulties created by the patient surge. RESULTS: The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital reconfigured human and physical resources differently from conventional drills. Graphical timelines illustrate anticipatory or reactive adaptations. The hospital's ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands. CONCLUSION: Adapting to beyond-surge capacity incident is essential to effective disaster response. Building organizational support for effective adaptation is critical for disaster planning.

Making Sense of the Cognitive Task of Medication Reconciliation Using a Card Sorting Task.

OBJECTIVE: To explore cognitive strategies clinicians apply while performing a medication reconciliation task, handling incomplete and conflicting information. BACKGROUND: Medication reconciliation is a method clinicians apply to find and resolve inconsistencies in patients' medications and medical conditions lists. The cognitive strategies clinicians use during reconciliation are unclear. Controlled lab experiments can explore how clinicians make sense of uncertain, missing, or conflicting information and therefore support the development of a human performance model. We hypothesize that clinicians apply varied cognitive strategies to handle this task and that profession and experience affect these strategies. METHOD: 130 clinicians participated in a tablet-based experiment conducted in a large American teaching hospital. They were asked to simulate medication reconciliation using a card sorting task (CaST) to organize medication and medical condition lists of a specific clinical case. Later on, they were presented with new information and were asked to add it to their arrangements. We quantitatively and qualitatively analyzed the ways clinicians arranged patient information. RESULTS: Four distinct cognitive strategies were identified ("Conditions first": n = 76 clinicians, "Medications first": n = 7, "Crossover": n = 17, and "Alternating": n = 10). The strategy clinicians applied was affected by their experience (p = .02) but not by their profession. At the appearance of new information, clinicians moved medication cards more frequently (75.2 movements vs. 49.6 movements, p < .001), suggesting that they match medications to medical conditions. CONCLUSION: Clinicians apply various cognitive strategies while reconciling medications and medical conditions. APPLICATION: Clinical information systems should support multiple cognitive strategies, allowing flexibility in organizing information.

Between choice and chance: the role of human factors in acute care equipment decisions.

OBJECTIVES: We report on a human factors evaluation project at a major urban teaching hospital that was intended to use human factors methods to assist the selection of a new infusion device among 4 commercially available models. METHODS: The project provided an expert evaluation of the pumps, collected data on programming each pump by a sample of practitioners, tabulated recent adverse event reports in the US Food and Drug Administration Manufacturer and User Device Experience database, and observed actual use in intensive care and hematology/oncology units. RESULTS: Programming by clinicians showed no correlation between clinical experience and ability to program any of the pumps under consideration. Field observations reflected diverse use patterns across services that required ease of use pumps did not offer. Upon review of a final candidate pump, purchasing preferences superceded clinical considerations. CONCLUSIONS: Equipment and systems that are intended for use by clinicians must necessarily reflect an understanding of actual clinical practice to be well suited for use at the sharp (operator) end. However, purchase decisions for medical equipment including infusion devices are typically made by hospital staff members who are experienced in administrative and clinical matters but have no expertise in the evaluation of complex equipment. This project demonstrates how collaboration by human factors and clinical professionals can inform equipment decisions and assist clinician performance to improve patient safety. It also reveals how technical decisions that directly influence anesthesia staff performance and patient safety are subject to organizational factors such as social and political pressure.

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

BACKGROUND: A widely reported ABO-mismatch accident in March of 2003 raised concerns about the reliability of the transplantation system. Because this type of failure is rare and significant, we performed a probabilistic risk assessment (PRA) of the donor-recipient matching processes for thoracic organ transplantation. METHODS: A probabilistic risk assessment was performed. RESULTS: The likelihood of accidental incompatible implantation was already low in 2003. The PRA model indicates that the likelihood of such an event was 1.38x10 per donated organ. This estimate correlates closely with the observed rate of these accidents. Based on this model, process changes put in place shortly after the accident reduced the probability to approximately 3.08x10 and changes put in place in October 2004 further reduced the probability to approximately 2.22x10 per organ donated. CONCLUSIONS: The observed and predicted likelihoods of accidental incompatible thoracic organ transplantation are comparable. These likelihoods are several orders of magnitude smaller than other hazards associated with solid organ transplantation. The PRA model indicates that changes that followed the March 2003 accident further reduced the likelihood of accidental incompatible implantation by roughly two orders of magnitude. Quantitative estimates from PRA can be used to assess risks in healthcare and to gauge the impact of system changes on these risks.

Improving patient safety by identifying side effects from introducing bar coding in medication administration.

OBJECTIVE: In addition to providing new capabilities, the introduction of technology in complex, sociotechnical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the implementation of bar code medication administration (BCMA), a technology designed to reduce adverse drug events (ADEs). DESIGN: Cross-sectional observational study of medication passes before (21 hours of observation of 7 nurses at 1 hospital) and after (60 hours of observation of 26 nurses at 3 hospitals) BCMA implementation. MEASUREMENTS: Detailed, handwritten field notes of targeted ethnographic observations of in situ nurse-BCMA interactions were iteratively analyzed using process tracing and five conceptual frameworks. RESULTS: Ethnographic observations distilled into 67 nurse-BCMA interactions were classified into 12 categories. We identified five negative side effects after BCMA implementation: (1) nurses confused by automated removal of medications by BCMA, (2) degraded coordination between nurses and physicians, (3) nurses dropping activities to reduce workload during busy periods, (4) increased prioritization of monitored activities during goal conflicts, and (5) decreased ability to deviate from routine sequences. CONCLUSION: These side effects might create new paths to ADEs. We recommend design revisions, modification of organizational policies, and "best practices" training that could potentially minimize or eliminate these side effects before they contribute to adverse outcomes.