Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions.

OBJECTIVES: In an effort to improve patient safety attitudes and skills among third-year medical students, two patient safety training sessions were added to their curriculum, complementing a previously implemented second-year curriculum on quality improvement, patient safety and teamwork. METHODS: Safety attitudes and skills were assessed before and after students completed the medicine clerkship training and were compared with historical controls. Students identified and reported on observed safety events, with their reports matched to event type and harm score with contemporaneous safety reports from University of Missouri's Patient Safety Network (PSN). Comparisons were assessed by five internal safety experts using criteria for report submission "worthiness", blame tone, target of blame and presence/strength of proposed solutions. RESULTS: Students completing the third-year safety booster conferences expressed statistically higher comfort levels with identifying the cause of an error than did the student control group (p<0.05). Medical students proposed safety interventions that were more robust than those suggested by event reporters regarding similar events within our health system (p<0.0001). The worthiness and blame tone of medical student reports were not statistically different than event reports in PSN. CONCLUSIONS: Completion of two 1-h patient safety booster conferences in the third year of medical school led to increased student comfort in safety event analysis. Students documented stronger resolution robustness scores, suggesting similar training should be offered to PSN reporters. Medical students represent an underutilised resource for identifying and proposing solutions for patient safety issues.

Human factors engineering design demonstrations can enlighten your RCA team.

A case study is presented, based on the experience of the US Veterans Affairs health system, which shows the benefits of healthcare personnel understanding human factors engineering (HFE) and how it relates to patient safety. After HFE training, personnel are better able to use a systems-oriented approach during adverse event analysis. Without some appreciation of HFE, the focus of adverse event analyses (e.g. root cause analysis (RCA)) is often misguided towards policies or an individual's shortcomings, leading to ineffective solutions. The case study followed the investigation by an RCA team of a retained sponge following cardiac surgery. The team began with a focus on the specific failings of the surgical nurse and outdated policies. HFE design demonstrations were used to redirect the team's focus to more systems-oriented issues, which could be uncovered even when events appeared to be related to policy or training, and to point them towards examining the design of systems that contributed to the event. The team was thus able to identify design flaws and make improvements to the design of the forms and computer systems that were key to preventing such events from recurring.

Human factors engineering and patient safety.

The case study and analyses presented here illustrate the crucial role of human factors engineering (HFE) in patient safety. HFE is a framework for efficient and constructive thinking which includes methods and tools to help healthcare teams perform patient safety analyses, such as root cause analyses. The literature on HFE over several decades contains theories and applied studies to help to solve difficult patient safety problems and design issues. A case study is presented which illustrates the vulnerabilities of human factors design in a transport monitor. The subsequent analysis highlights how to move beyond the more obvious contributing factors like training to design problems and the establishment of informal norms. General advice is offered to address these issues and design issues specific to this case are discussed.

Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.

BACKGROUND: The Veterans Administration (VA) identified patient safety as a high-priority issue in 1997 and implemented the Patient Safety Improvement (PSI) initiative throughout its entire health care system. In spring 1998 the External Panel on Patient Safety System Design recommended alternative methods to enhance reporting and thereby improve patient safety. REDESIGNING THE PSI INITIATIVE: The VA began redesigning the PSI initiative in late 1998. The dedicated National Center for Patient Safety (NCPS) was established. Using the panel's recommendations as a jumping-off point, NCPS began to identify known and suspected obstacles to implementation (such as possible punitive consequences and additional workload). NCPS adopted a prioritization scoring method, the Safety Assessment Code (SAC) Matrix, for close calls and adverse events, which requires assessing the event's actual or potential severity and the probability of occurrence. The SAC Matrix specifies actions that must be taken for given scores. Use of the SAC score permits a consistent handling of reports throughout the VA system and a rational selection of cases to be considered. A system for performing a root cause analysis (RCA) was developed to guide caregivers at the frontline. This system includes a computer-aided tool, a flipbook containing a series of six questions, and reporting of the findings back to the reporter. The final step requires that the facility's chief executive officer "concur" or "nonconcur" on each recommended corrective action. The RCA team outlines how the effectiveness of the corrective action will be evaluated to verify that the action has had the intended effect, and it ascertains that there were no unintended negative consequences. IMPLEMENTATION: Based on successful implementation in two pilots, full-scale national rollout to the 173 facilities began in April 2000 and was concluded by the end of August 2000. NCPS supplied 3 days of training for individuals at each facility. The training included didactic components, an introduction to human factors engineering concepts, and small- and large-group simulation exercises. Facility leaders were reminded of the necessity to reinforce the point that assignment to an RCA team was considered an important duty. DISCUSSION: It is essential to design and implement a system that takes into account the concerns of the frontline personnel and is aimed at being a tool for learning and not accountability. The system must have as its primary focus the dissemination of positive actions that reduce or eliminate vulnerabilities that have been identified, not a counting exercise of the number of reports.

Developing a culture of patient safety at the VA.

Patient safety is a topic that has become prominent in the minds of many, both within and outside the healthcare field over the past several months. But in fact, literature in medical journals describing this topic goes back decades. However, studying these issues is only the first step towards developing useful and practical tools to address errors and does little to change the safety culture that underlies these systems. The VA has taken several steps towards a safety culture and the development and implementation of tools, such as: 1) error reporting mechanisms; 2) tools for root cause and corrective action; and 3) management tools (e.g., safety awards).

A human-centered approach to medical informatics for medical students, residents, and practicing clinicians.

The authors have developed a curriculum in medical informatics that focuses on practical problems in clinical medicine, rather than on the details of informatics technologies. Their development of this human-centered curriculum was guided by the identification of six key clinical challenges that must be addressed by practitioners in the near future and by an examination of the failures of past informatics efforts to make a significant difference in the everyday practice of clinical medicine. Principles of human factors engineering--the body of knowledge about those human abilities, limitations, and characteristics that are relevant to design--are an essential part of this curriculum. Human factors engineering also provides the necessary perspective, as well as the concrete knowledge and methods, that can enable practitioners to properly evaluate their clinical information needs, weight the merits of proposed technology-based solutions, and understand their own inherent performance limitations.

Simulation of blood flow in microgravity.

Knowledge of venous, capillary, and arterial blood flow in microgravity is required to modify hemostatic techniques for control of bleeding in traumatic injuries or surgical procedures in space. To simulate human arterial, venous, and capillary bleeding, fresh whole bovine blood was injected by two operators at calculated flow rates (3.5, 7, and 14 mL for venous and 14 and 28 mL for arterial) in 10 seconds with empirical controls in a lucent glove box during zero gravity parabolic flight on NASA's KC-135 aircraft. A pig's foot was used to mimic capillary bleeding. Hemostasis with sponges and laerdal suction was evaluated by video and still photography. Evaluations of the arterial and venous bleeding were conducted at 3 rates x 3 parabolas, and capillary bleeding was evaluated with 5 parabolas x 2 methods (pig's foot and sponge). Influenced by surface tension, the slow venous bleeding coated syringe surfaces and formed a dome over the skin laceration bleeding site. Arterial and venous bleeders broke into uniform spheres with low-velocity spheres bouncing off an absorbent pad and suction tip. Conventional dabbing with gauze fragmented blood into small spheres. Capillary oozing was better controlled by "wicking" up blood with gauze. Repeated arterial bleeding opacified the glove box wall. This stimulation demonstrated unique characteristics of extracorporeal blood flow and inadequacies of common methods of hemostasis in microgravity.

Geographic disorientation: approaching and landing at the wrong airport.

Geographic disorientation in aviation operations results from the failure of an aircrew to recognize and/or maintain the desired position relative to the external ground and airspace environment. Becoming lost during flight, intruding inadvertently into unauthorized airspace, selecting a wrong airway, landing on the wrong runway, and approaching the wrong airport--with or without actual landing--are some examples of inflight geographic disorientation. This is a relatively common phenomenon that can be experienced by any pilot, regardless of experience level and the type of pilot certification. This paper analyzes 75 cases of geographic disorientation that occurred among air carrier pilots plus 16 cases among general aviation pilots between 1982 and 1987. Inflight geographic disorientation can result from a variety of aeromedical and human factors (aircrew, operational, environmental) which, interacting with each other, create the ideal conditions for the occurrence of this phenomenon. The adverse consequences of geographic disorientation for the aircrew, passengers and aircraft are delineated along with specific preventive measures.

Potassium, corticosterone, and adrenocorticotropic hormone release in vitro.

Incubation of rat adenohypophyses in a high concentration of potassium increases adrenocorticotropic hormone release. This increased release is suppressed by the addition of corticosterone to the incubating medium. Our findings are consistent with a process of "stimulus-secretion coupling" proposed for other glands and suggest that corticosterone may operate directly on the adenohypophysial cell membrane to inhibit releasing mechanisms.