Human Factors Principles Research Articles

Human factors in anaesthesia: a narrative review.

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Shape Matters: A Neglected Feature of Medication Safety : Why Regulating the Shape of Medication Containers Can Improve Medication Safety.

This paper aims to highlight how to reduce medication errors through the implementation of human factors science to the design features of medication containers. Despite efforts to employ automation for increased safety and decreased workload, medication administration in hospital wards is still heavily dependent on human operators (pharmacists, nurses, physicians, etc.). Improving this multi-step process requires its being studied and designed as an interface in a complex socio-technical system. Human factors engineering, also known as ergonomics, involves designing socio-technical systems to improve overall system performance, and reduces the risk of system, and in particular, operator, failures. The incorporation of human factors principles into the design of the work environment and tools that are in use during medication administration could improve this process. During periods of high workload, the cognitive effort necessary to work through a very demanding process may overwhelm even expert operators. In such conditions, the entire system should facilitate the human operator's high level of performance. Regarding medications, clinicians should be provided with as many perceptual cues as possible to facilitate medication identification. Neglecting the shape of the container as one of the features that differentiates between classes of medications is a lost opportunity to use a helpful characteristic, and medication administration failures that happen in the absence of such intentional design arise from "designer error" rather than "user error". Guidelines that define a container's shape for each class of medication would compel pharmaceutical manufacturers to be compatible and would eliminate the confusion that arises when a hospital changes the supplier of a given medication.

Unintended consequences of pharmacy information systems: A case study

BackgroundPharmacy information systems (PhIS) can cause medication errors that pharmacists may overlook due to their increased workload and lack of understanding of maintaining information quality. This study seeks to identify factors influencing unintended consequences of PhIS and how they affect the information quality, which can pose a risk to patient safety. Materials and MethodsThis qualitative, explanatory case study evaluated PhIS in ambulatory pharmacies in a hospital and a clinic. Data were collected through observations, interviews, and document analysis. We applied the socio-technical interactive analysis (ISTA) framework to investigate the socio-technical interactions of pharmacy information systems that lead to unintended consequences. We then adopted the human–organization–process–technology-fit (HOPT-fit) framework to identify their contributing and dominant factors, misfits, and mitigation measures. ResultsWe identified 28 unintended consequences of PhIS, their key contributing factors, and their interrelations with the systems. The primary causes of unintended consequences include system rigidity and complexity, unclear knowledge, understanding, skills, and purpose of using the system, use of hybrid paper and electronic documentation, unclear and confusing transitions, additions and duplication of tasks and roles in the workflow, and time pressure, causing cognitive overload and workarounds. Recommended mitigating mechanisms include human factor principles in system design, data quality improvement for PhIS in terms of effective use of workspace, training, PhIS master data management, and communication by standardizing workarounds. ConclusionThreats to information quality emerge in PhIS because of its poor design, a failure to coordinate its functions and clinical tasks, and pharmacists’ lack of understanding of the system use. Therefore, safe system design, fostering awareness in maintaining the information quality of PhIS and cultivating its safe use in organizations is essential to ensure patient safety. The proposed evaluation approach facilitates the evaluator to identify complex socio-technical interactions and unintended consequences factors, impact, and mitigation mechanisms.

Using human factors principles to redesign a 3D lab workflow during the COVID-19 pandemic

BackgroundLike most hospitals, our hospital experienced COVID-19 pandemic-related supply chain shortages. Our additive manufacturing lab’s capacity to offset these shortages was soon overwhelmed, leading to a need to improve the efficiency of our existing workflow. We undertook a work system analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) construct which is based on human factors and quality improvement principles. Our objective was to understand the inefficiencies in project submission, review, and acceptance decisions, and make systematic improvements to optimize lab operations.MethodsContextual inquiry (interviews and workflow analysis) revealed suboptimal characteristics of the system, specifically, reliance on a single person to facilitate work and, at times, fractured communication with project sponsors, with root causes related to the project intake and evaluation process as identified through SEIPS tools. As interventions, the analysis led us to: 1) enhance an existing but underused project submission form, 2) design and implement an internal project scorecard to standardize evaluation of requests, and 3) distribute the responsibility of submission evaluation across lab members. We implemented these interventions in May 2021 for new projects and compare them to our baseline February 1, 2018 through – April 30, 2021 performance (1184 days).ResultsAll project requests were submitted using the enhanced project submission form and all received a standardized evaluation with the project scorecard. Prior to interventions, we completed 35/79 (44%) of projects, compared to 12/20 (60%) of projects after interventions were implemented. Time to review new submissions was reduced from an average of 58 days to 4 days. A more distributed team responsibility structure permitted improved workflow with no increase in staffing, allowing the Lab Manager to devote more time to engineering rather than administrative/decision tasks.ConclusionsBy optimizing our workflows utilizing a human factors approach, we improved the work system of our additive manufacturing lab to be responsive to the urgent needs of the pandemic. The current workflow provides insights for labs aiming to meet the growing demand for point-of-care manufacturing.

Patient Safety Challenges in the Pandemic: Applying Human Factors Principles to Embed Patient Safety and Experience at the Clinical Front Line

The COVID-19 pandemic has amplified systemic gaps in patient safety, including social frailty for vulnerable populations such as older adults (Briguglio et al., 2020). Public health measures, such as prolonged and frequent lockdowns, restricted access to visitors and support networks and in extreme cases led to confinement within a single room, The negative impact of these restrictions has focused new attention on social frailty, which has hitherto been a somewhat neglected patient safety issue. Since social frailty is a multifaceted construct, it needs to be considered in a variety of settings and from a range of disciplinary perspectives. This practitioner-led panel consisting of an internist, a human factors engineer, an occupational therapist, and an implementation scientist, examines the impact of the pandemic on social interaction, and social frailty amongst older people in three different settings (hospital, long term care home, community). Through a set of case studies, the panelists provided applied experiences and perspectives on the impact of the pandemic on patient safety and on social frailty in particular. The panel covered theory, and real-world application of human factors principles. The question of how to design safety into the healthcare system were also explored. In this paper we review the problem of social frailty, list some brief case studies and discuss possible intervention strategies.

Human Factors in the Systems Engineering Jungle

EXTENDED ABSTRACT As holistic thinking goes, the effects of the system on the human are well-known in the HFES community. However, many practitioners have experienced the challenges of incorporating these effects into a life cycle approach. Systems engineering seeks to model, predict, and employ holistic thinking in the development of multi-part and complex systems (NASA Systems Engineering Handbook). It is posited that a systemic approach and integration of human factors (HF) would better streamline various process pieces, thus reducing life cycle costs and risks to system and human functionality in the deployed system. Systems engineering processes and human factors philosophies have run parallel and intersecting courses, but rarely are they well-integrated. Despite the demonstrated impact of consideration on operators and users early in the design process for the reduction of system life cycle costs, and on increased adoption of systems by those users – few resources and tools exist that allow practitioners to translate human factors principles into Systems Engineering. These same practitioners are often called upon as experts within a systems development process. Limited participation on integrated product teams (IPTs), constrained and niche issue studies, and late life cycle validation all contribute to the challenges of holistic system integration, eventually passing frustration on to the users. The recent introduction of Human Readiness Levels (HRLs), which provide corresponding metrics to the well-established Technology Readiness Levels (TRLs), is one critical tool that will be faciliatory for appropriate consideration of human capabilities and limitations as part of system design (ANSI- HFES 400-2021). Tools like these that can become standard practices will be invaluable for inclusion of the human element into programs of record. However, in many instances, the practical considerations of conducting engineering design are often left to the individual practitioner to figure out. While many academic resources highlight the importance of including HF into system design and development, few resources exist to support in-the-trenches development efforts. In addition, communication of the value of human systems engineering across disciplines is consistently and persistently a challenge and incorporated as part of project contracts and plans to only a limited extent. This panel explores the issue, tales from the jungle, and success stories from multiple points of view, including practitioners of Human Factors, Systems Engineers, and Academics.

Implementing Root Cause Analysis and Action: Integrating Human Factors to Create Strong Interventions and Reduce Risk of Patient Harm.

The goal of this study was to develop a systems approach for root cause analysis and action to achieve strong, sustainable interventions. The team integrated human factors principles into the design of interventions to ensure solutions maintain compatibility with human capabilities and limitations resulting in stronger solutions to prevent reoccurrence. This study was conducted at a 7-hospital health system located in southwestern Virginia. Including human factors in a new root cause analysis and action process allowed the team to design strong interventions. To assess the results of this process, a team evaluated all interventions over a 4-year period (2.75-y preimplementation and 1.4-y postimplementation). Interventions were initially blind coded and then consensus coding was executed to finalize the strength of each intervention according to the VA National Center for Patient Safety evaluation tool. The new process resulted in an efficient method to address adverse events with increased staff satisfaction and interventions more resilient to human error. The number of events with strong interventions increased from 43% to 69% after implementation of the new process. Tailoring an event investigation process to an organizational culture is critical to implementation success. Adding human factors into the design of interventions helped facilitate intervention implementation and sustainability. Blinded ratings showed that with the integration of human factors, there was improved strength of interventions. This indicates that a focus on strong system improvement (rather than weaker individual human-based solutions) will lead to improved staff satisfaction and patient safety.

Human factors applications in the design of decision support systems for population health: a scoping review

IntroductionPublic health professionals engage in complex cognitive tasks, often using evidence-based decision support tools to bolster their decision-making. Human factors methods take a user-centred approach to improve the design of...

Application and Evaluation of a Non-Accident-Based Approach to Road Safety Analysis Based on Infrastructure-Related Human Factors

Too often the identification of critical road sites is made by “accident-based” methods that consider the occurred accidents’ number. Nevertheless, such a procedure may encounter some difficulties when an agency does not have reliable and complete crash data at the site level (e.g., accidents contributing factors not clear or approximate accident location) or when crashes are underreported. Furthermore, relying on accident data means waiting for them to occur with the related consequences (possible deaths and injuries). A non-accident-based approach has been proposed by PIARC. This approach involves the application of the Human Factors Evaluation Tool (HFET), which is based on the principles of Human Factors (HF). The HFET can be applied to road segments by on-site inspections and provides a numerical performance measure named Human Factors Scores (HFS). This paper analyses which relationship exists between the results of the standard accident-based methods and those obtainable with HFET, based on the analysis of self-explaining and ergonomic features of the infrastructure. The study carried out for this purpose considered 23 km of two-way two-lane roads in Italy. A good correspondence was obtained, meaning that high risky road segments identified by the HFS correspond to road segments already burdened by a high number of accidents. The results demonstrated that the HFET allows for identifying of road segments requiring safety improvements even if accident data are unavailable. It allows for improving a proactive NSS, avoiding waiting for accidents to occur.

Cognitive Distractions During Sonographic Procedures: Reducing Noise-Based and Light-Based Interruptions in Hospital Rooms

Sonographers experience a high cognitive load in hospital-based care. High ambient noise and frequent noise-based interruptions include knocking on the room door, questions from others in the room or through communication technology, alarms, alerts from personal devices, and carts and people passing in the hallway. In addition, other providers turning on the overhead light is distracting for exams that need to be conducted in reduced lighting conditions. This article suggests strategies to improve working conditions for sonographers conducting exams on a patient in the hospital room. Our strategies emerge from human factors methods and principles, which derive from communication principles and theory. These strategies are organized by reducing noise-based and light-based interruptions in the hospital room and hallway, primarily through changes to the built environment and communication technology settings and reducing the use of speech during cognitively challenging time periods through training. Most of the strategies are low-cost and can be implemented within the current built environment and communication technology infrastructure. We anticipate that these strategies could enhance patient outcomes, increase patient satisfaction, improve sonographers’ job satisfaction, protect provider health, and increase procedural efficiency.

163 Go Big or Go Home: The Use of Large-Scale Simulation

In 2019, we carried out our first experimental large-scale simulation exercise with great success. The initial findings of the study were presented at ASPiH 2019. This is an update on our journey using large-scale inter-professional simulation (IPE). From our initial simulation, we identified the following key themes: (1) students’ educational expectations; (2) their experience of multi-disciplinary working; (3) the theory to practice gap and (4) gaining experience in a safe environment. From this, we realized that our students needed more of this type of simulation activity and that the hands-off facilitation style that we used helped with learning and preparation for practice. Students responded positively to having to put their leadership skills into practice, learning in a safe environment in a real-time situation, something that, despite great placements, they often felt unable to do in the ‘real world’. This real-time simulation-enhanced innovative thinking and emphasized human factor principles. This type of learning experience promoted learning and working together across the multi-disciplinary field with both qualified and pre-registration students. The impact of working with ‘qualified’ professionals added to the realism of the simulation. We found that the debrief was key in the development of real-time simulation as it was enhanced by good-quality debriefing. Following the initial large-scale simulation, we planned and delivered two more events before COVID-19 prevented us from continuing. Both were large-scale events, but we made adaptations each time to enhance the students’ learning experience. What we have managed to achieve over the lockdown period is to plan and prepare for further events and, in hindsight, this has better prepared us. So, what have we done in this period of enforced distancing? We have gone through a period of change management to align all our curriculum to being simulation-based, and have developed and implemented a framework for the integration of skills and simulation. We have sent (nearly) all our lecturing staff from across our courses, nursing, operating department practitioner, midwifery, paramedic, trainee nursing associate and social work on a simulation train the trainer course to understand the pedagogy and discipline that is the backbone of simulation. This has been a great success and has generated a lot of inter-professional conversations and development of simulation. We have designed and developed a large-scale simulation that can be run in a COVID compliant way.

Using a human factors-centric approach to development and testing of a face shield designed for health care workers: A COVID-19 case study for process and outcomes

BackgroundFace shields are a critical piece of personal protective equipment and their comfort impacts compliant use and thus protectiveness. Optimal design criteria for face shield use in healthcare environments are limited. We attempt to identify factors affecting face shield usability and to test and optimize a face shield for comfort and function in health care settings. MethodsA broad range of workers in a large health care system were surveyed regarding face shield features and usability. Quantitative and qualitative analysis informed the development of iterative prototypes which were tested against existing shields. Iterative testing and redesign utilized expert insight and feedback from participant focus groups to inform subsequent prototype designs. ResultsFrom 1,648 responses, 6 key elements were identified: ability to adjust tension, shifting load bearing from the temples, anti-fogging, ventilation, freedom of movement, and durability. Iterative prototypes received consistently excellent feedback based on use in the clinical environment, demonstrating incremental improvement. ConclusionWe defined elements of face shield design necessary for usability in health care and produced a highly functional face shield that satisfies frontline provider criteria and Emergency Use Authorization standards set by the Food and Drug Administration. Integrating human factors principles into rapid-cycle prototyping for personal protective equipment is feasible and valuable.

Development of an evidence-based ESCALATION system for recognition and response to paediatric clinical deterioration

AimThe aim of this study was to develop an evidence-based paediatric early warning system for infants and children that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care. MethodsA three-stage intervention development framework consisted of Stage 1: evidence review, benchmarking, stakeholder (health professionals, decision-makers, and health consumers) engagement, and consultation; Stage 2: planning and coproduction by the researchers and stakeholders using action research cycles; and Stage 3: prototyping and testing. ResultsA prototype evidence-based system incorporated human factor principles, used a structured approach to patient assessment, promoted situational awareness, and included family as well as clinician concern. Family involvement in detecting changes in their child's condition was supported by posters and flyers codesigned with health consumers. Five age-specific observation and response charts included 10 weighted variables and one unweighted variable (temperature) to convey a composite early warning score. The escalation pathway was supported by a targeted communication framework (iSoBAR NOW). ConclusionThe development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was a novel component of the system.

Systematic review of medical literature for medicolegal claims and complaints involving neonates

ImportanceComplaints and malpractice claims by families on the care of their babies are pertinent issue. Beyond just the financial implications, it involves harm to babies and distress to parents.ObjectiveThe aim...

Developing Conversational Agents for Use in Criminal Investigations

The adoption of artificial intelligence (AI) systems in environments that involve high risk and high consequence decision-making is severely hampered by critical design issues. These issues include system transparency and brittleness, where transparency relates to (i) the explainability of results and (ii) the ability of a user to inspect and verify system goals and constraints; and brittleness, (iii) the ability of a system to adapt to new user demands. Transparency is a particular concern for criminal intelligence analysis, where there are significant ethical and trust issues that arise when algorithmic and system processes are not adequately understood by a user. This prevents adoption of potentially useful technologies in policing environments. In this article, we present a novel approach to designing a conversational agent (CA) AI system for intelligence analysis that tackles these issues. We discuss the results and implications of three different studies; a Cognitive Task Analysis to understand analyst thinking when retrieving information in an investigation, Emergent Themes Analysis to understand the explanation needs of different system components, and an interactive experiment with a prototype conversational agent. Our prototype conversational agent, named Pan, demonstrates transparency provision and mitigates brittleness by evolving new CA intentions. We encode interactions with the CA with human factors principles for situation recognition and use interactive visual analytics to support analyst reasoning. Our approach enables complex AI systems, such as Pan, to be used in sensitive environments, and our research has broader application than the use case discussed.

A human factors analysis of the Stretch mobile manipulator robot

Assistive and mobile robots have potential to support everyday domestic tasks and enable independence for persons in the home. As a first step to evaluating this potential, we assessed the initial unboxing and setup of Hello Robot’s Stretch RE1– a novel mobile manipulator designed for domestic settings. All study procedures took place in the McKechnie Family LIFE Home, which is a smart home research facility on the University of Illinois Urbana-Champaign campus. We used subject matter experts (SMEs) and followed human factors principles to consider obstacles users with diverse needs and capabilities (e.g., older adults, persons with mobility disabilities) might encounter during the unboxing process. We then conducted 50 trials of user testing and critical task analyses in the LIFE home to assess the feasibility and usability for different use cases. Research team members controlled Stretch by using a game controller. We used Stretch to manipulate 15 different types of objects that would be part of domestic activities needed to live independently, such as tasks needed for meal preparation. We documented the frequency of errors, time spent manipulating the object, and informal qualitative feedback from teleoperators during and after each trial (using a think-aloud protocol). Implications for future domestic robot design using human factors approaches are discussed.

Best Practices for Reducing Interface Errors in Electronic Medical Records

As Electronic Medical Records (EMR) become increasingly prevalent, the application of human factors principles is essential to facilitate efficiency and usability of these systems and, in turn, to reduce adverse patient outcomes due to user errors relating to the EMR. This paper describes five “best practices” found in the literature which aim to prevent error in the use of Electronic Medical Records. These practices are: Watermarking, Information Control and Management, Hybrid Systems, Cross-Checking Methodology, and Interface Modification. The paper describes each practice and examines the research underlying each approach. Although some practices may be easier to apply than others, they all merit further research and have potential for error prevention on a large scale.

Home blood pressure data visualization for the management of hypertension: using human factors and design principles

BackgroundHome blood pressure measurements have equal or even greater predictive value than clinic blood pressure measurements regarding cardiovascular outcomes. With advances in home blood pressure monitors, we face an imminent flood of home measurements, but current electronic health record systems lack the functionality to allow us to use this data to its fullest. We designed a data visualization display for blood pressure measurements to be used for shared decision making around hypertension.MethodsWe used an iterative, rapid-prototyping, user-centred design approach to determine the most appropriate designs for this data display. We relied on visual cognition and human factors principles when designing our display. Feedback was provided by expert members of our multidisciplinary research team and through a series of end-user focus groups, comprised of either hypertensive patients or their healthcare providers required from eight academic, community-based practices in the Midwest of the United States.ResultsA total of 40 participants were recruited to participate in patient (N = 16) and provider (N = 24) focus groups. We describe the conceptualization and development of data display for shared decision making around hypertension. We designed and received feedback from both patients and healthcare providers on a number of design elements that were reported to be helpful in understanding blood pressure measurements.ConclusionsWe developed a data display for substantial amounts of blood pressure measurements that is both simple to understand for patients, but powerful enough to inform clinical decision making. The display used a line graph format for ease of understanding, a LOWESS function for smoothing data to reduce the weight users placed on outlier measurements, colored goal range bands to allow users to quickly determine if measurements were in range, a medication timeline to help link recorded blood pressure measurements with the medications a patient was taking. A data display such as this, specifically designed to encourage shared decision making between hypertensive patients and their healthcare providers, could help us overcome the clinical inertia that often results in a lack of treatment intensification, leading to better care for the 35 million Americans with uncontrolled hypertension.

When Human Factors Fails: Intentional and Unintentional Bad Designs

The primary goal of human factors is to create systems that can be easily used by their intended audience, while minimizing the number of mistakes that a user might make. However, sometimes human factors principles are applied in ways that makes a user’s task harder. Sometimes this is intentional, and the designer uses human factors as justification for creating an exclusionary design. In other cases, it is unintentional, and the application of human factors was done in a haphazard or incomplete way, with the resulting design at cross-purposes with the original intent. In either case, that’s bad human factors.

A Tool for Evaluating Medication Alerting Systems: Development and Initial Assessment.

BackgroundIt is well known that recommendations from electronic medication alerts are seldom accepted or acted on by users. Key factors affecting the effectiveness of medication alerts include system usability and alert design. Thus, human factors principles that apply knowledge of human capabilities and limitations are increasingly used in the design of health technology to improve the usability of systems.ObjectiveThis study aims to evaluate a newly developed evidence-based self-assessment tool that allows the valid and reliable evaluation of computerized medication alerting systems. This tool was developed to be used by hospital staff with detailed knowledge of their hospital’s computerized provider order entry system and alerts to identify and address potential system deficiencies. In this initial assessment, we aim to determine whether the items in the tool can measure compliance of medication alerting systems with human factors principles of design, the tool can be consistently used by multiple users to assess the same system, and the items are easy to understand and perceived to be useful for assessing medication alerting systems.MethodsThe Tool for Evaluating Medication Alerting Systems (TEMAS) was developed based on human factors design principles and consisted of 66 items. In total, 18 staff members recruited across 6 hospitals used the TEMAS to assess their medication alerting systems. Data collected from participant assessments were used to evaluate the validity, reliability, and usability of the TEMAS. Validity was assessed by comparing the results of the TEMAS with those of prior in-house evaluations. Reliability was measured using Krippendorff α to determine agreement among assessors. A 7-item survey was used to determine usability.ResultsThe participants reported mostly negative (n=8) and neutral (n=7) perceptions of alerts in their medication alerting system. However, the validity of the TEMAS could not be directly tested, as participants were unaware of any results from prior in-house evaluations. The reliability of the TEMAS, as measured by Krippendorff α, was low to moderate (range 0.26-0.46); however, participant feedback suggests that individuals’ knowledge of the system varied according to their professional background. In terms of usability, 61% (11/18) of participants reported that the TEMAS items were generally easy to understand; however, participants suggested the revision of 22 items to improve clarity.ConclusionsThis initial assessment of the TEMAS allowed the identification of its components that required modification to improve usability and usefulness. It also revealed that for the TEMAS to be effective in facilitating a comprehensive assessment of a medication alerting system, it should be completed by a multidisciplinary team of hospital staff from both clinical and technical backgrounds to maximize their knowledge of systems.