Human Factors Interventions Research Articles

Understanding the human factors challenge of handover between levels of automation for uncrewed air systems: a systematic literature review

ABSTRACT Using uncrewed air systems (UASs) as part of the logistics chain is anticipated to reduce overall operating costs and speed up delivery. One particular challenge faced by UAS operators is in handover between high levels of autonomous control and piloted control. This review presents the findings from the published literature based on the human factors of handover between levels of automation within different domains. A total of 188 full publications were reviewed of which 52 publications were included. The literature outlines several challenges in transition of handover in publications focussing on UASs, crewed flight, healthcare, maritime, robotics and air traffic control. Interventions included interface design, training strategies, the design of the automation itself to support the operator and organisational design opportunities. There is currently only a small literature base, understanding the application of human factors interventions and their benefits to this unique application needs to be better understood to support effective operational safety.

Development of effective human factors interventions for aviation safety management.

In the aviation industry, safety management has moved away from capturing frontline failures toward the management of systemic conditions through organizational safety management systems (SMS). However, subjective differences can influence the classification of active failures and their associated systemic precursors. With levels of professional experience known to influence safety attitudes, the present research examines whether experience levels among airline pilots had an impact on the classification of causal factors using the Human Factors Analysis and Classification System (HFACS). Differences in the paths of association between categories were evaluated in an open-system context. Pilots working in a large, international airline were categorized into high (≥10,000 total flight hours) and low (<10,000 h) experience groups and asked to classify aircraft accident causal factors using the HFACS framework. One-way ANOVA tests were carried out to determine experience effects on the utilization of the HFACS categories, and chi-squared analyses were used to assess the strength of association between different categories within the framework. Results from 144 valid responses revealed differences in the attribution of human factors conditions. The high experience group was more inclined to attribute deficiencies to high-level precursors and found fewer paths of associations between different categories. In contrast, the low experience group presented a greater number of associations and was comparatively more affected by stress and uncertainty conditions. The results confirm that the classification of safety factors can be influenced by professional experience, with hierarchical power distance impacting the attribution of failures to higher-level organizational faults. Different paths of association between the two groups also suggest that safety interventions can be targeted through different entry points. Where multiple latent conditions are associated, the selection of safety interventions should be made with consideration of the concerns, influences, and actions across the entire system. Higher-level anthropological interventions can change the interactive interfaces affecting concerns, influences, and actions across all levels, whereas frontline-level functional interventions are more efficient for failures linked to many precursor categories.

Improving Sepsis Compliance With Human Factors Interventions in a Community Hospital Emergency Room

Background: Adherence to best practices for sepsis management at a small community hospital was below system, state, and national benchmarks and affected vital indicators, including mortality. This study aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions. Methods: The Plan-Do-Study-Act quality improvement methodology was used for this project. Baseline metrics included sepsis bundle compliance following CMS (Centers for Medicare &amp; Medicaid Services) core measure standards, hospital morality, sepsis triage screening, and physician order set use. Interventions: Several human factors workflows and tools were used to boost early identification with screening opportunities and enhance staff awareness of sepsis indicators. Results: With the interventions, the hospital’s compliance with sepsis best practice treatment improved by a 23 percentage-point increase from baseline. Sepsis triage screening also increased and remained consistent after project interventions. Conclusions: With the project, using human factors tools enhanced staff engagement and increased sepsis awareness. Engagement increased sepsis identification and screening in a small community hospital setting.

The Relevance of Attention Control, Not Working Memory, in Human Factors.

Discuss the human factors relevance of attention control (AC), a domain-general ability to regulate information processing functions in the service of goal-directed behavior. Working memory (WM) measures appear as predictors in various applied psychology studies. However, measures of WM reflect a mixture of memory storage and controlled attention making it difficult to interpret the meaning of significant WM-task relations for human factors. In light of new research, complex task performance may be better predicted or explained with new measures of attention control rather than WM. We briefly review the topic of individual differences in abilities in Human Factors. Next, we focus on WM, how it is measured, and what can be inferred from significant WM-task relations. The theoretical underpinnings of attention control as a high-level factor that affects complex thought and behavior make it useful in human factors, which often study performance in complex and dynamic task environments. To facilitate research on attention control in applied settings, we discuss a validated measure of attention control that predicts more variance in complex task performance than WM. In contrast to existing measures of WM or AC, our measures of attention control only require 3minutes each (10minutes total) and may be less culture-bound making them suitable for use in applied settings. Explaining or predicting task performance relations with attention control rather than WM may have dramatically different implications for designing more specific, equitable task interfaces, or training. A highly efficient ability predictor can help researchers and practitioners better understand task requirements for human factors interventions or performance prediction.

A Human Factors Approach to Vaginal Retained Foreign Objects

This study aimed to apply a structured human factors analysis to understand conditions contributing to vaginal retained foreign objects (RFOs). All potential vaginal RFO events from January 1, 2000, to May 21, 2019, were analyzed by trained human factors researchers. Each narrative was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare. An 890-bed, academic medical center in Southern California. Patients who underwent a vaginal procedure in which a vaginal RFO-related event occurred were included in this study. However, no patient information was included, and only the relevant details from their procedures were included. No interventions were developed or implemented. Over the 19-year period, 45 events were reported. The most common items were vaginal packing and vaginal sponges (53.33%). Less frequently retained items involved broken instruments (20.20%). Most cases were laparoscopic hysterectomies or vaginal deliveries. Based on the Human Factors Analysis and Classification System, 75 contributing factors were identified, consisting primarily of preconditions for unsafe acts (communication challenges, coordination breakdowns and issues with the design of tools/technology) and unsafe acts (errors). Although rare, vaginal RFOs do occur. The top 2 contributing factors were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.

A human factors intervention in a hospital - evaluating the outcome of a TeamSTEPPS program in a surgical ward

BackgroundPatient safety in hospitals is being jeopardized, since too many patients experience adverse events. Most of these adverse events arise from human factors, such as inefficient teamwork and communication failures, and the incidence of adverse events is greatest in the surgical area. Previous research has shown the effect of team training on patient safety culture and on different areas of teamwork. Limited research has investigated teamwork in surgical wards. The aim of this study was to evaluate the professional and organizational outcomes of a team training intervention among healthcare professionals in a surgical ward after 6 and 12 months. Systems Engineering Initiative for Patient Safety 2.0 was used as a conceptual framework for the study.MethodsThis study had a pre-post design with measurements at baseline and after 6 and 12 months of intervention. The intervention was conducted in a urology and gastrointestinal surgery ward in Norway, and the study site was selected based on convenience and the leaders’ willingness to participate in the project. Survey data from healthcare professionals were used to evaluate the intervention. The organizational outcomes were measured by the unit-based sections of the Hospital Survey of Patient Safety Culture Questionnaire, and professional outcomes were measured by the TeamSTEPPS Teamwork Perceptions Questionnaire and the Collaboration and Satisfaction about Care Decisions in Teams Questionnaire. A paired t-test, a Wilcoxon signed-rank test, a generalized linear mixed model and linear regression analysis were used to analyze the data.ResultsAfter 6 months, improvements were found in organizational outcomes in two patient safety dimensions. After 12 months, improvements were found in both organizational and professional outcomes, and these improvements occurred in three patient safety culture dimensions and in three teamwork dimensions. Furthermore, the results showed that one of the significant improved teamwork dimensions “Mutual Support” was associated with the Patient Safety Grade, after 12 months of intervention.ConclusionThese results demonstrate that the team training program had effect after 12 months of intervention. Future studies with larger sample sizes and stronger study designs are necessary to examine the causal effect of a team training intervention in this context.Trial registration numberISRCTN13997367 (retrospectively registered).

Implementing a human factors approach to RCA2 : Tools, processes and strategies.

Root Cause Analysis and Action (RCA2 ) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and development of systems-level interventions. We recently integrated a complement of human factors tools into the RCA2 process to address this gap. These tools include the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a multiple-criterion decision tool called FACES, for selecting effective HFIX solutions. We describe each of these tools and illustrate how they can be integrated into RCA2 to create a robust human factors RCA process called HFACS-RCA2 . We also present qualitative results from an 18-month implementation study within a large academic health center. Results demonstrate how HFACS-RCA2 can foster a more comprehensive, human factors analysis of serious patient harm events and the identification of broader system interventions. Following HFACS-RCA2 implementation, RCA team members (risk managers and quality improvement advisors) also experienced greater satisfaction in their work, leadership gained more trust in RCA findings and recommendations, and the transparency of the RCA process increased. Effective strategies for overcoming implementation barriers, including changes in roles, responsibilities and workload will also be presented.

An Analysis of FDA Adverse Event Reporting Data for Trends in Medical Device Use Error

Humans can contribute to error at all stages of the medical device product life-cycle. Use error associated with medical devices can result in catastrophic consequences for end users and inefficient use of healthcare system resources. Industry-wide statistics about medical device use error has the potential to aid in identifying opportunities for human factors intervention, however publicly available statistics are sparse. The Food and Drug Administration (FDA) requires medical device manufactures, importers, and device user facilities to track and report adverse events for post-market surveillance through medical device reports (MDRs). This data is available in an online database: Manufacturer and User Facility Experience (MAUDE). This study provides a comprehensive evaluation of use error adverse events in MAUDE (2010-2018) based on device class, device operator, and event outcome, to address the lack of industry-wide statistics on medical device use error. Results indicate that use error is significantly represented in adverse event reporting, constituting 28.1% of reports labeled with device problem codes. Events associated with patient device operators were predominately associated with diabetes-related medical devices, while provider operators were associated with a wider array of devices. Additionally, it was found that most use error reports were attributed to issues with device output; using the device in accordance with manufacturer expectations; and physically activating, positioning, or separating device components. This work demonstrates the viability of using MAUDE to attain industry wide statistics on medical device use error for later integration in industry-wide or device-specific risk mitigation strategies.

MP05-20 VAGINAL RETAINED FOREIGN OBJECTS: APPLYING A HUMAN FACTORS PERSPECTIVE

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse (MP05)1 Apr 2020MP05-20 VAGINAL RETAINED FOREIGN OBJECTS: APPLYING A HUMAN FACTORS PERSPECTIVE Colby P. Souders *, Tara Cohen, Kai Dallas, Kate Cohen, Falisha Kanji, Carrie Stewart, and Jennifer Anger Colby P. Souders *Colby P. Souders * More articles by this author , Tara CohenTara Cohen More articles by this author , Kai DallasKai Dallas More articles by this author , Kate CohenKate Cohen More articles by this author , Falisha KanjiFalisha Kanji More articles by this author , Carrie StewartCarrie Stewart More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000819.020AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retained foreign objects (RFO) after surgery are a serious and preventable issue. Gawande et al (2003) found that the incidence of RFOs in 22 hospitals ranged from 1 in 8,801 to 1 in 18,760 and that retained vaginal sponges accounted for 22% of all retained foreign bodies. Although rare, these events can have severe consequences for both the patients, providers, and hospitals, and can often lead to litigation. We performed a human factors analysis, which is the discipline of studying the interactions of humans and systems, to understand and develop interventions that may help prevent vaginal RFOs. METHODS: We analyzed the safety events reported to our internal tracking system from January 1, 2000 - May 21, 2019 and filtered specifically by potential and actual vaginal RFOs. These events were then categorized into vaginal RFO “Near Misses” (RFO identified before patient leaves the OR) and “Sentinel Events” (RFO not identified before patient leaves the OR). The event reports were then analyzed by three trained human factors researchers. The conditions surrounding each event were analyzed and categorized into the Human Factors Analysis and Classification System (HFACS). RESULTS: 45 events were reported in the 19-year period. The majority of the events analyzed were categorized as “near misses.” The most common items in question (53.33%) were Raytecs, vaginal packing, and vaginal sponges. However, another common instance was breaking of an instrument (20.20%) while operating in the vagina. The majority of cases were laparoscopic hysterectomies or vaginal deliveries. Based on our human factors analysis, the most common contributing factor involved skill-based errors, such as counting errors, followed by issues with communication and shortcomings in the design of tools/technologies (see Table 1). CONCLUSIONS: Fortunately, the occurrence of vaginal RFOs is rare. According to our analysis, the top two contributing factors are skill-based errors and communication, neither of which would have been addressed without the application of a human factors approach. Moreover, both types of errors can be addressed and improved with human factors interventions such as simulation and teamwork training to streamline workflow to reduce the opportunity for errors. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e49-e50 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Colby P. Souders * More articles by this author Tara Cohen More articles by this author Kai Dallas More articles by this author Kate Cohen More articles by this author Falisha Kanji More articles by this author Carrie Stewart More articles by this author Jennifer Anger More articles by this author Expand All Advertisement PDF downloadLoading ...

Human Factors and Sociotechnical Issues.

Summary Objective : To summarize significant research contributions on human factors (HF) and organizational issues in medical informatics published in 2018. Methods : An extensive search using PubMed/Medline and Web of Science ® was conducted to identify the scientific contributions published in 2018 that address human factors and organizational issues in medical informatics. The selection process comprised three steps: (i) 15 candidate best papers were first selected by the two section editors, (ii) external reviewers from internationally renowned research teams reviewed each candidate best paper, and (iii) the final selection of four best papers was conducted by the editorial board of the Yearbook. Results : The four selected best papers are excellent contributions to the HF literature: they show the added value of HF studies by providing nice illustrated and rigorous interventions. Conclusion : HF interventions are known to have great potential to contribute to efficient HIT design, but the interventions still face challenges in successfully demonstrating their value to the main stakeholders of the healthcare domain. There is a need to strengthen the demand for high-quality HF studies by increasing awareness among powerful stakeholders of the value of high-quality HF studies.

A Data-Driven Approach to Team Training for Nurses in a Level II Trauma Center.

This prospective investigation describes the process of designing a targeted, data-driven team training aimed at reducing identified process inefficiencies or flow disruptions (FDs) that threaten the optimal delivery of trauma care. Trained researchers observed and classified FDs during 34 trauma cases in a Level II trauma center. Multidisciplinary trauma personnel generated interventions to identified issues using the human factors intervention matrix (HFIX). This article focuses on one intervention: a formal trauma nurse training program centered around leadership, teamwork, and communication. The training was well perceived and was found to have a significant impact on participant knowledge of course content; t (65) = -13.92, p ≤ .01. By using hospital-specific data to drive intervention development from multidisciplinary team members, it is possible to develop effective solutions aimed at addressing individual threats.

FMARI Application in Innovation and IT for Accidents' Investigation

FMARI Database Application is designed to help safety auditor in investigating work accidents and as routine monitoring in regular companies reports to safety board organization in Indonesia (BPJS for Employee) with the main goal is to reach zero accident. FMARI stands for Faktor Manusia dan Analisis Resiko Industri (application: Human Factors and Industrial Risk Analysis) is following HFACS method and make a modification from HFIX in Indonesian terms. The Human Factors Analysis and Classification System (HFACS) is a system-safety model that effectively bridges the gap between human error theory and applied human error analysis. The Human Factors Intervention matriX (HFIX) is an innovative tool for mapping intervention strategies onto the specific forms of human error identified in the HFACS.

Study protocol – Interventions to reduce musculoskeletal occupational injury in surgeons and interventionalists: A systematic review

Musculoskeletal occupational injury is prevalent within the surgical community. This is a multi-factorial issue, but is contributed to by physical posture, environmental hazards and administrative deficiency. There is growing awareness of this issue, with several behavioural, educational and administrative techniques being employed. The literature on this topic is, however, sporadic and difficult to access by healthcare practitioners.The primary aim of this systematic review is to evaluate the literature on the current interventions used to minimise musculoskeletal occupational injury in surgeons. This review will focus on administrative, human factor interventions and ergonomics training.

Improving emergency surgical care for patients with right iliac fossa pain at a regional scale: A quality improvement study using the Supported Champions implementation strategy

IntroductionMethods to improve clinical systems safety suffer from significant difficulties in implementation and scaling up. We used an upscaling implementation strategy entitled Supported Champions in a quality and safety improvement programme for emergency surgery at regional level, focusing on patients with right iliac fossa pain. MethodsA before-after study was conducted across four acute NHS Trusts: A 6 month intervention phase was preceded and followed by 3 months of data collection. An established Human Factors intervention was led at each Trust by a small group of staff selected as Champions. Champions received training in teamwork and systems improvement and were supported by Human Factors experts. The primary improvement aim was to expedite surgery for patients with sepsis, using Royal College of Surgeons emergency surgery guidelines as the measure. Additional outcomes studied included length of inpatient stay and 30-day readmission rates. ResultsBreaches of RCS urgency guidelines decreased markedly from 13.7% of operated patients pre-intervention to 3.5% post-intervention (p = 0.000). Mean time from booking to incision decreased in three of the four sites, whilst median length of stay increased in 3 of 4. Overall 30-day readmission rate remained stable (7.84% pre-intervention versus 7.31% post-intervention, p = 0.959). DiscussionThe Supported Champions model allowed all surgical teams to reduce delay for septic patients by more than 50%, using distinct Quality Improvement strategies to address local issues. Improvement was implemented in 4 diverse settings with a quarter of the level of expert input previously used in a single hospital.

A transfusion prescription template and other human factor interventions to improve balanced transfusion delivery in major haemorrhage due to trauma.

The aim of this study is to improve practice in the management of major haemorrhage, particularly in red cell to plasma transfusion ratios. A review of the management of major haemorrhage in trauma in Newcastle Hospitals Trust in 2012-2013 showed good mortality outcomes but found that red cell:plasma transfusion ratios could be improved. Human factors techniques transferable from industry and the military were identified, and a package of interventions was implemented, including an intensive multidisciplinary team training programme and a new major haemorrhage prescription template. We reviewed the management of all 243 adult trauma patients admitted with major haemorrhage to the Emergency Department in the Newcastle Hospitals Trust in the 4-year period from April 2012. We analysed clinical details, blood components transfused and patient outcomes and used Trauma Audit and Research Network data to correlate with injury severity and predicted survival. Mean transfusion ratios of red cells to plasma improved from 1·5:1 and 1·6:1 in the first 2 years to 1·1:1 in the 2 years following implementation of the new measures. There was a statistically significant improvement in the delivery of a balanced transfusion, defined as a red cell:plasma ratio of <1·3:1 following the changes. Simple changes to procedures, specifically implementation of a new major haemorrhage prescription template and multidisciplinary team training, have resulted in marked improvement in the ratio of red cells to plasma transfused to trauma patients with major haemorrhage or requiring emergency blood. The package of changes could be easily replicated in other health-care settings.

Improving the Quality of Ward-based Surgical Care With a Human Factors Intervention Bundle.

This study aimed to explore the impact of a human factors intervention bundle on the quality of ward-based surgical care in a UK hospital. Improving the culture of a surgical team is a difficult task. Engagement with stakeholders before intervention is key. Studies have shown that appropriate supervision can enhance surgical ward safety. A pre-post intervention study was conducted. The intervention bundle consisted of twice-daily attending ward rounds, a "chief resident of the week" available at all times on the ward, an escalation of care protocol and team contact cards. Twenty-seven junior and senior surgeons completed validated questionnaires assessing supervision, escalation of care, and safety culture pre and post-intervention along with interviews to further explore the impact of the intervention. Patient outcomes pre and postintervention were also analyzed. Questionnaires revealed significant improvements in supervision postintervention (senior median pre 5 vs post 7, P = 0.002 and junior 4 vs 6, P = 0.039) and senior surgeon approachability (junior 5 vs 6, P = 0.047). Both groups agreed that they would feel safer as a patient in their hospital postintervention (senior 3 vs 4.5, P = 0.021 and junior 3 vs 4, P = 0.034). The interviews confirmed that the safety culture of the department had improved. There were no differences in inpatient mortality, cardiac arrest, reoperation, or readmission rates pre and postintervention. Improving supervision and introducing clear protocols can improve safety culture on the surgical ward. Future work should evaluate the effect these measures have on patient outcomes in multiple institutions.

P103: A human factors-based framework analysis for patient safety: the trauma resuscitation using in situ simulation team training (TRUST) experience

Introduction: Effective trauma resuscitation requires a coordinated team approach, yet there is a significant risk for error. These errors can manifest from sequential system-, team- and knowledge based failures, defined as latent safety threats (LSTs). In situ simulation (ISS), a point-of-care training strategy, provides a novel prospective approach to identify factors that impact patient safety. This study quantified and formulated a hierarchy of LSTs during risk-informed ISS trauma resuscitations. Methods: At a Level 1 trauma centre, we conducted 12 multi-disciplinary, unannounced ISSs to prospectively identify trauma-related LSTs. Four, risk-informed scenarios were developed based on 5 recurring themes found within the trauma program’s morbidity and mortality process. The actual, on-call trauma team participated in the study. Simulations were video recorded with 4 cameras, each positioned at a different angle. Using a framework analysis methodology, human factors experts transcribed and coded the videos. Thematic structure was established deductively based on existing literature and inductively based on observed ISS events. All LSTs were prioritized for future patient safety, systems and ergonomic interventions using the Healthcare Failure Mode and Effect Analysis (HFMEA) matrix. Results: We identified 893 LSTs from 12 simulations. LST analysis resulted in 8 themes subcategorized into 43 codes. Themes were associated with team-, knowledge- or system-related issues. The following themes emerged: situational awareness, provider safety, mental model alignment, team/individual responsibility, team resources, equipment considerations, workplace environment and clinical protocols. The HFMEA hazard scoring process identified 13 high priority codes that required urgent attention and intervention to mitigate negative patient outcomes. Conclusion: A prospective, video-based framework analysis represents a novel and robust approach to LST identification within trauma care. Patterns of LSTs within and between simulations provide a high degree of transparency and traceability for an inter-professional trauma program review. Hazard matrix scoring facilitates the classification and prioritization of human factors interventions intended to improve patient safety.

Decreased transport time to the surgical intensive care unit

IntroductionExtended stay in the emergency department (ED) is associated with worse outcomes in critically ill trauma patients. We conducted a human factors analysis to better understand impediments for patient flow when a surgical ICU (SICU bed is available in order to reduce ED LOS. MethodsThis is a retrospective review of all trauma patients admitted to a protected SICU through the ED during 2011 and 2014. In 2010, a 24-hour protected SICU bed protocol was implemented to make a bed readily available. During 2013 human factors analysis helped to describe flow disruptions; related interventions were introduced to facilitate rapid transport from the ED to SICU. The interventions required the following prior to CT scanning: immediate ICU bed orders placed by the ED physician and ED to ICU personnel communication. Direct transport from the CT scanner to the ICU was mandated. Data including patient demographics, injury severity, ED LOS, ICU LOS, and hospital LOS was collected and compared between 2011 (PRE) and 2014 (POST). ResultsA total of 305 trauma patients admitted from the ED to the SICU were analyzed; 174 patients in 2011 (PRE) and 131 in 2014 (POST). Average age was 46 years and patients had a mean admission GCS and injury severity score (ISS) of 12.3 and 15.9, respectively. The cohorts were similar in age, mechanism of injury, initial vital signs, and injury severity. After implementing the human factors interventions, decreases were noted in the mean ED LOS (2.4 v. 3.0 hours, p=0.005) and ICU LOS (4.0 v. 4.8 days, p=0.023). No differences in hospital LOS or mortality were observed. ConclusionsWhile an open SICU bed protocol may facilitate rapid transport of trauma patients from the ED to the ICU, additional human factors interventions emphasizing improved communication and coordination can further reduce time spent in the ED. Level of EvidenceLevel IV, Economic/Decision.

Good to Great: Quality-Improvement Initiative Increases and Sustains Pediatric Health Care Worker Hand Hygiene Compliance.

The Joint Commission, the Centers for Disease Control and Prevention, and the World Health Organization challenge hospitals to achieve and sustain compliance with effective hand hygiene (HH) practice; however, many inpatient units fail to achieve a high level of reliability. The aim of the project was to increase and sustain health care worker (HCW) compliance with HH protocols from 87% (level of reliability [LOR] 1) to ≥95% (LOR 2) within 9 months on 2 pediatric inpatient units in an academic children's hospital. This study was a time-series, quality-improvement project. Interventions were tested through multiple plan-do-study-act cycles on 2 pediatric inpatient units. HH compliance audits of HCWs on these units were performed randomly each week by the hospital infection prevention program. Control charts of percentages of HCW HH compliance were constructed with 3-σ (data within 3 SDs from a mean) control limits. These control limits were adjusted after achieving significant improvements in performance over time. Charts were annotated with interventions including (1) increasing awareness, (2) providing timely feedback, (3) empowering patients and families to participate in mitigation, (4) providing focused education, and (5) developing interdisciplinary HH champions. HH compliance rates improved from an average of 87% (LOR 1) to ≥95% (LOR 2) within 9 months, and this improvement has been sustained for >2 years on both pediatric inpatient units. Significant and sustained gains in HH compliance rates of ≥95% (LOR 2) can be achieved by applying high-reliability human-factor interventions.

The challenges of improving peripherally inserted central catheter (PICC) care instructions at hospital discharge.

175 Background: Teaching patients and caregivers to manage a Peripherally Inserted Central Catheter (PICC) line placed during hospitalization is essential to successful outpatient transitions. The aim was to improve written care instructions at hospital discharge (CIHD) given to solid tumor oncology patients with new PICC lines by creating an electronic template in the electronic health record. Methods: Inpatients with newly placed PICC lines discharged from the physician assistants' (PA) oncology teams at Brigham and Women's Hospital were identified through PICC team consult lists. We identified 9 elements of complete line care, modeled on National Quality Forum discharge metrics, to include in a template for PICC line care instructions at discharge. PAs received instruction on template use at their weekly meeting. A retrospective chart review of CIHD (February 19, 2016 and October 13, 2016) was performed. Results: A total of 47 cases were reviewed, 19 cases Pre-introduction and 28 cases Post. Before introduction of the template, 74% of cases lacked PICC care instructions (including 13 cases with no mention of the PICC line), 26% had incomplete care instructions, and none had full instructions. Following the intervention, 64% still lacked care instructions (16 cases with no mention of the PICC line), 21% had incomplete care instructions, and 4 patients (14%) had full instructions. Only those CIHD that used the template had complete care instructions. A c-chart demonstrated special cause variation following the intervention but the process was chaotic. Conclusions: The introduction of a template for PICC care instructions led to modest improvement in the number of patients discharged with full instructions. This project highlights the limitations of solutions that incorporate technical solutions but only weak adaptive ones. The next phase of our work will introduce human factors interventions (e.g. automation and forcing functions) to improve the success rate of this critically important function. [Table: see text]