Workflow Interruptions Research Articles

Importance of Mobile Photography in Dental Practice

This letter aims to explain the importance of using cell phones to take helpful images with high efficiency in various types of dental procedures. In our dental practices’ photography is an effective tool. Its applications are widespread such as in the diagnosis and treatment planning, keeping an illustrative clinical history, legal documentation, publishing, and delivering lectures.1 In modern dentistry, photography has grown into a standard of treatment. With the advent of digital technology these days, photography has now become simpler and widely available. Even then, few practitioners introduce them in their daily practices due to reasons such as a lack of expertise in cameras, lenses, and technique, disruption of workflow, and cost considerations. The use of smartphones with improved technology, however, is constantly emerging. It allows every practitioner with minimal interruptions in their patient workflow to incorporate photography into his or her practice.2 Making images from mobile in dentistry has multi-level importance. Its implementation in dental practice is simple, swift, and extremely useful in recording working practices, conducting health promotion sessions, and administering clinical examinations, thus providing dentists and patients with many advantages.1-2

Code Blue in the Operating Room—pharmacy is on the way!

BackgroundPharmacists have become an integrated part of the cardiac arrest (Code Blue) response team in the emergency department and inpatient settings. However, the attendance of pharmacists at intraoperative codes is less established. ObjectiveThe purpose of this paper was to describe the creation of the Perioperative Pharmacy Attendance for Intraoperative Codes Safety Initiative, report the impact it had on the intraoperative emergency code team, and discuss the limitations and difficulties experienced by the pharmacy department so that other institutions may have a foundation on which to build similar programs. Practice descriptionA large academic medical center successfully incorporated pharmacists into the intraoperative emergency code team. Practice innovationWe began by obtaining collaborative leadership support by using a quality assurance and improvement focus. In an organized manner, we methodically developed workflow protocols, educational programming, and promotional material to ensure that our initiative was able to be effectively used by the institution. Evaluation methodsA year after the implementation, clinicians evaluated the program and reported its impact on team performance. An evaluation regarding the difficulties experienced with the initiation of the program was also performed. ResultsMost clinicians stated that having pharmacists at intraoperative emergencies improved patient care as well as the code team’s performance. The difficulties experienced during the development of this program included workflow disruptions and the need for a continued effort to effectively advertise it to clinicians. ConclusionOur institution was able to create the successful Perioperative Pharmacy Attendance for Intraoperative Codes Safety Initiative. This paper describes the steps taken to create and implement this successful program as well as the integration of pharmacists into the intraoperative emergency setting.

The Effects of Flow Disruptions on RN Circulators.

The RN circulator role includes maintaining situational awareness and mitigating risks to patient safety in the OR. Flow disruptions-deviations that threaten the safe and efficient flow of surgery-may contribute to the occurrence of errors and negatively affect safety for patients and health care providers. We used an existing data set to explore the effects of flow disruptions on the RN circulator. To create the data set, doctoral-level human factors students observed 24 cardiac surgery procedures and recorded the types and durations of disruptions. We used a human factors taxonomy to classify the flow disruptions. Of the 1,470 events observed, interruptions were most prevalent (66.67%), followed by coordination issues (15.37%) and communication breakdowns (8.37%). Layout (7.21%), equipment (1.77%), and usability (0.61%) issues accounted for the remainder of the disruptions. Perioperative leaders should work with staff members to minimize workflow disruptions and provide support for identifying and documenting flow disruptions.

Senior Lecturers’ Learning Mechanisms During Emergency Remote Teaching at Binus University

The research aimed to identify senior lecturers’ experiences with online teaching during ERT (Emergency Remote Teaching). The ominous Covid-19 forced tertiary education institutions in Indonesia to employ ERT, both synchronous and asynchronous online teaching, from March 2020. Not all existing lecturers were professionally ready for this change, specifically senior lecturers who had been teaching for more than 25 years. These senior lecturers entered into unfamiliar territory as they had been experiencing the drastic transition to ERT. This transition could be viewed as a learning process as they went through certain learning mechanisms. The qualitative method was used to examine the learning mechanisms of senior lecturers who have been teaching during this ERT. This method was appropriate, as it allowed an understanding of lecturers’ experience in their professional growth. This case study examined five senior lecturers who have been teaching English as a Foreign Language at the university level for more than 25 years. Data analysis followed the procedures developed by Braun and Clarke. The research finds that each lecturer experiences learning mechanisms, including identification, coordination, reflection, and transformation. During the identification, they learn to understand the needs to adapt, adopt, and change. They also experience different kinds of unfamiliar events that have to be faced. They adapt to the unfamiliar situation during the phase of coordination through reading, joining webinars (web seminars), and mentoring during the coordination. Each of them reflects on the process of shifting boundaries of their competencies or knowledge from previously teaching offline to online. The last learning mechanism is the transformation that leads to profound changes after experiencing disruptions in the current workflow. Those multiple disruptions shape them in facing ERT.

Never Enough Time: Mixed Methods Study Identifies Drivers of Temporal Demand That Contribute to Burnout Among Physicians Who Care for Pediatric Hematology-Oncology Patients.

Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment because of chronic occupational stress. Approximately one third of pediatric hematology-oncology physicians experience burnout. The goal of this mixed methods study was to determine the prevalence and drivers of burnout among physicians caring for pediatric hematology-oncology patients at our institution. This mixed methods, cross-sectional study was conducted at a large academic cancer center. Validated survey instruments were used to measure burnout, job demands, experience with patient safety events, and workplace culture. Quantitative data informed development of a semistructured interview guide, and physicians were randomly selected to participate in individual interviews. Interviews were transcribed and analyzed via content analysis based on a priori codes. The survey was distributed to 132 physicians, and 53 complete responses were received (response rate 40%). Of the 53 respondents, 15 (28%) met criteria for burnout. Experiencing burnout was associated with increased temporal demand. Twenty-six interviews were conducted. Qualitative themes revealed that frequent meetings, insufficient support staff, and workflow interruptions were key drivers of temporal demand and that temporal demand contributed to burnout through emotional exhaustion and reduced personal accomplishment. Nearly one-third of participating physicians met criteria for burnout, and burnout was associated with increased temporal demand. Qualitative interviews identified specific drivers of temporal demand and burnout, which can be targeted for intervention. This methodology can be easily adapted for broad use and may represent an effective strategy for identifying and mitigating institution-specific drivers of burnout.

Beyond EDC

INTRODUCTION: The last two decades have seen Electronic Data Capture (EDC) scale the adoption curve in the therapeutic development industry. The history of EDC adoption can inform development and implementation of similar, future advances. OBJECTIVE: This synthesis documents the progression to EDC in clinical research towards improving the development, implementation, and use of emerging and similar technology in multicenter clinical studies. METHODS: The 158 full-text sources identified in the Good Clinical Data Management Practices (GCDMP)systematic literature search were used as the basis for this scoping review.  A single reader evaluated this literature to determine rationale for and barriers to EDC implementation as well as remaining gaps in the use and optimization of EDC technology in clinical research. Quantitative evaluations of EDC technology were identified and summarized. Two reviewers examined the findings to identify omitted seminal work and alternate perspectives. RESULTS: Metrics and outcomes used in EDC evaluation are detailed. Three major gaps between current EDC implementation and fully realized electronically supported clinical trials. Similarities and differences between EDC and new clinical study technology highlighted to improve methods in implementation and evaluation of new technology in clinical studies.   CONCLUSIONS: Foreseeable implementation challenges delayed but did not necessarily extend the EDC adoption curve relative to contemporaneous innovation. Multiple adjunct new technologies have potential to surpass the current EDC performance plateau. Of these, direct EHR-to-eCRF data collection parallels EDC in terms of workflow disruption and technology interaction at clinical sites. Thus, similar adoption challenges are expected. Based on our observations, if developing standards are successful, they will make data more quickly and computationally accessible to significantly broaden opportunities for therapeutic development beyond those available in today’s EDC.

Reducing Cardiac Telemetry Nuisance Alarms Through Evidence-Based Interventions.

Cardiac telemetry nuisance alarms due to leads off and poor signal increase staff workflow interruptions, decrease staff trust in technology, and can compromise patient safety. Interventions were directed at reducing nuisance alarms on a 32-bed, non-intensive care - a cardiac telemetry unit. A nursing staff education module with evidence-based practices for reducing nuisance alarms, a daily care protocol for patients on cardiac telemetry monitoring, and daily audits of protocol adherence were implemented. Staff pre- and posttest comparisons on their knowledge relating to nuisance alarms and the evidence-based protocol demonstrated a significant mean increase of 3.02 (95% CI, 2.55-3.48). Daily audits for 7 weeks demonstrated an average of 58.46% staff adherence. Telemetry technician call volume reduction was 16% postimplementation, while nuisance alarms were not reduced significantly. This rapid-cycle, quality improvement process resulted in minimal reduction in nuisance alarms but improved staff awareness of the issue and reduced workflow interruptions.

Research and Exploratory Analysis Driven-Time-data Visualization (read-tv) software.

MotivationResearch & Exploratory Analysis Driven Time-data Visualization (read-tv) is an open source R Shiny application for visualizing irregularly and regularly spaced longitudinal data. read-tv provides unique filtering and changepoint analysis (CPA) features. The need for these analyses was motivated by research of surgical work-flow disruptions in operating room settings. Specifically, for the analysis of the causes and characteristics of periods of high disruption-rates, which are associated with adverse surgical outcomes.Materials and Methods read-tv is a graphical application, and the main component of a package of the same name. read-tv generates and evaluates code to filter and visualize data. Users can view the visualization code from within the application, which facilitates reproducibility. The data input requirements are simple, a table with a time column with no missing values. The input can either be in the form of a file, or an in-memory dataframe– which is effective for rapid visualization during curation.ResultsWe used read-tv to automatically detect surgical disruption cascades. We found that the most common disruption type during a cascade was training, followed by equipment.Discussion read-tv fills a need for visualization software of surgical disruptions and other longitudinal data. Every visualization is reproducible, the exact source code that read-tv executes to create a visualization is available from within the application. read-tv is generalizable, it can plot any tabular dataset given the simple requirements that there is a numeric, datetime, or datetime string column with no missing values. Finally, the tab-based architecture of read-tv is easily extensible, it is relatively simple to add new functionality by implementing a tab in the source code.Conclusion read-tv enables quick identification of patterns through customizable longitudinal plots; faceting; CPA; and user-specified filters. The package is available on GitHub under an MIT license.

Lessons learned from pharmacy learner and educator experiences during early stages of COVID-19 pandemic.

DisclaimerIn an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PurposeTo explore pharmacy learner (eg, resident, fellow) and educator (eg, residency program director, preceptor) experiences and lessons learned during the coronavirus disease 2019 (COVID-19) pandemic.MethodsIn May 2020, attendees of the virtual Research in Education and Practice Symposium (REPS) were invited to participate in two 1-hour networking sessions. During these sessions, participants completed individual and group reflection exercises during which they were asked questions about their experiences during the initial stages of the COVID-19 pandemic. Participants who volunteered submitted their responses through an electronic survey application. Anonymous responses were coded using thematic analysis to address the research questions.ResultsSixty-eight and 38 participants, respectively, attended the 2 networking discussions. Participant-identified professional impacts of the COVID-19 crisis included unexpected learning experiences, greater adaptability, workflow and learning interruptions, and decreased productivity. Personal impacts included a greater focus on well-being, physical and social isolation, and changes in travel plans. Participants noted positive and negative emotions including acceptance, encouragement, anxiety, stress, and frustration. The main lessons learned focused on adaptability, gratitude, and empathy. Participants indicated that they would have from foreknowledge of the anticipated duration of the pandemic, associated workflow changes, and the reliance on technology the pandemic would engender. In addition, they predicted that pharmacy practice will require changes to workflow flexibility, training expectations, the pharmacist’s role, and organizational structure.ConclusionThe COVID-19 pandemic has positively and negatively impacted the professional and personal lives of pharmacy learners and educators, with the most notable impacts being in the areas of well-being and adaptability. Future research should explore the experiences of other workforce personnel and evaluate the long-term impact on pharmacy practice, patient outcomes, and workforce well-being and resiliency.

Development of a process map for the delivery of virtual clinical pharmacy services at Odette Cancer Centre during the COVID-19 pandemic.

Virtual methods have been innovatively utilized to provide clinical and supportive care to patients with cancer. Oncology pharmacists have been actively involved in this movement, in order to minimize patient contact and decrease the risk of viral transmission for this high-risk group. In response to COVID-19 restrictions, the Odette Cancer Centre pharmacy modified the delivery of clinical pharmacy services (CPS), including medication histories and patient education/counseling, to a remote telephone-based model. Process maps were created to visualize workflow before and after the pandemic. Process metrics were tracked over a 6-week period. From March 25th to May 1st, 2020, 202 best-possible medication histories and baseline assessments were completed; 149 of these (74%) were completed remotely. For medication therapy counsels, 72 of 199 were completed remotely (36%). Despite workflow disruptions caused by the pandemic, these results demonstrate that clinical pharmacy service levels could be maintained by incorporating remote delivery approaches without significant investment in resources. Challenges included acceptance by patients and lack of technology to support system-level processes. Further research to develop, refine, and individualize virtual clinical pharmacy care models will help to consolidate the role of these approaches in the post-COVID-19 era.

Implementing Health Care Quality Measures in Electronic Health Records: A Conceptual Model.

There is significant literature on the development and validation of quality measures, but comparably less on their implementation into learning health systems. Electronic Health Records (EHRs) have made vast amounts of data available for quality improvement purposes. In this paper we describe a conceptual model for EHR implementation of quality measures. The model involves five steps: (1) select a measure; (2) define measure criteria; (3) validate criteria and measurement process; (4) improve recording of measure-related activity; and (5) engage quality improvement processes. The model was used to develop and implement a quality measure in the Home-Based Medical Care (HBMC) setting. Harris Health House Call Program (HHHC) provides primary medical and palliative care for homebound patients in Houston. Four-hundred twenty-four primary care patients followed in the HHHC. Completion rate of the 9-item Patient Health Questionnaire (PHQ-9) within the Electronic Health Record of newly enrolled HHHC patients. Use of the conceptual model to guide implementation of a quality measure of depression screening in a HMBC practice was successful. Additional components of early leadership and clinician buy-in were required, as well as strong relationships with IT to ease implementation and limit disruptions in clinicians' work-flow. This conceptual model was feasible for guiding implementation of a quality measure for depression care of HBMC patients, and it can guide broader implementation of EHR-based quality measures in the future.

Preparing junior radiology residents for overnight call via peer-led, hands-on simulation.

The aim of this study was to assess the perceived value and impact of a hands-on mock call simulation program on resident confidence with interpretation of emergency department overnight call cases. A five-session course was implemented in June of 2018 for rising PGY-3/R2 residents to mimic the experience of overnight call with indirect supervision. Sessions were led by senior residents in the program and consisted of timed, independent interpretation of 15-20 high-yield cases per day which highlighted "do-not miss" critical findings and simulated workflow interruptions including phone calls, consultations, and questions from technologists. IRB-approved, and anonymous pre- and post-course surveys were administered to participants which assessed residents' degree of confidence in interpretation of on-call cases and comparison of the mock call experience with existing preparatory strategies. Survey responses were analyzed using McNemar's test and Mann-Whitney U test. Our survey response rate was 91% (29/32). After completing the mock call simulation, there was a significant increase in the mean Likert score of resident confidence levels and feelings of preparedness from 4.59 to 7.38 (p < 0.01). The majority of respondents (72.4% [21/29]) felt that the mock call simulation was "extremely useful." One hundred percent of respondents indicated that the mock call simulation should be implemented for the following year. Implementation of a hands-on mock call simulation significantly improves the confidence levels of radiology residents before assuming on-call responsibilities and may serve as an adjunct to existing preparatory strategies.

Psychiatry after-hours: factors impacting workload and workflow.

The study evaluated the workload and workflow of registrars engaged in a psychiatry after-hours roster, quantified their perceptions of this experience and provided recommendations for system redesign. Multiple sources of information, including medical student observers and telephone logs, quantified the tasks performed during shifts. Registrars completed a satisfaction questionnaire. After-hours shifts often started with a lack of attendance of key clinicians at handover. Tasks handed over and completed during shifts varied; there was very little difference between evening, weekends and night shifts except for the higher likelihood of seclusion reviews on weekends. Registrars experienced a significant and complex workload including emergency department and ward reviews, and admissions. Workflow interruptions were frequent; the high number of phone calls and critical incidence warrant further investigation. Registrars were confident in their own ability, but had less confidence in other key clinicians. Many registrars did not discuss after-hours work during supervision. The after-hours experience of psychiatry registrars at a university hospital is arduous and includes a wide range of clinical tasks. This activity is an essential service provision undertaking as well as a training activity. This must be weighed against the impact of after-hours work on registrar well-being.

Clinical trial enrollment at a rural satellite hospital during COVID-19 pandemic.

Controlled clinical trials (CCTs) have traditionally been limited to urban academic clinical centers. Implementation of CCTs in rural setting is challenged by lack of resources, the inexperience of patient care team members in CCT conductance and workflow interruption, and global inexperience with remote data monitoring. We report our experience during the coronavirus disease 2019 (COVID-19) pandemic in activating through remote monitoring a multicenter clinical trial (the Study of Efficacy and Safety of Canakinumab Treatment for cytokine release syndrome (CRS) in Participants with COVID-19-induced Pneumonia [CAN-COVID] trial, ClinicalTrials.gov Identifier: NCT04362813) at a rural satellite hospital, the VCU Health Community Memorial Hospital (VCU-CMH) in South Hill, VA, that is part of the larger VCU Health network, with the lead institution being VCU Health Medical College of Virginia Hospital (VCU-MCV), Richmond, VA. We used the local resources at the facility and remote guidance and oversight from the VCU-MCV resources using a closed-loop communication network. Investigational pharmacy, pathology, and nursing were essential to operate the work in coordination with the lead institution. Fifty-one patients with COVID-19 were enrolled from May to August 2020, 35 (69%) at VCU-MCV, and 16 (31%) at VCU-CMH. Among the patients enrolled at VCU-CMH, 37.5% were female, 62.5% Black, and had a median age of 60 (interquartile range 56-68) years. Local decentralization of this trial in our experience gave rural patients access to a novel treatment and also accelerated enrollment and more diverse participants' representative of the target population.

394. Pseudo-outbreak of Coagulase-negative Staphylococcus Species from Blood Cultures Highlights Unique Challenges in Care of Critically Ill Patients With COVID-19

BackgroundIn response to the COVID-19 pandemic, a dedicated intensive care unit for patients infected with SARS-CoV-2 was created at our institution. We noticed a marked increase in the number of blood cultures positive for coagulase-negative Staphylococcus species (CoNS) that highlights unique challenges that arise with the creation of new units and workflows.MethodsWe reviewed all blood culture results from the COVID-19 intensive care unit (CoVICU) from April 15 to May 29. We reviewed all blood cultures taken from the oncology ward, medical intensive care unit (MICU), and emergency department (ED) for the same time frame as a comparison. We calculated contamination rates, using the clinical microbiology laboratory criteria for possible contaminants based on species and number of positive blood cultures.ResultsThere were 324 total blood cultures collected from the CoVICU with 27/324 (8.3%) positive for organisms deemed contaminant, 10/324 (3.1%) were positive considered bloodstream infections (BSI); the ratio of BSI:contaminant was 1:2.7. For the MICU, ED, and oncology units contamination rates were 2/197 (1%), 33/747 (4.4%), and 2/334 (0.6%), respectively; and the ratio of BSI:contaminant was 5:1, 2.2:1, and 17.5:1, respectively. There was a significant relationship between contamination rates and unit, X2(3, N = 1602) = 30.85, p < 0.001.ConclusionUpon investigation, peripheral blood draw kits were not stocked in the CoVICU. Additionally, certain components of standard work for blood culture collection (e.g. glove exchange) could not be performed per usual practice due to isolation precautions. Peripheral blood draws were routinely performed by nurses in CoVICU and MICU while phlebotomy performed these in other comparison units. We suspect that lack of availability of blood draw kits and disruption of typical workflow in isolation rooms contributed to an unusually high number of contaminated blood cultures among patients admitted to the CoVICU. Notably, the CoVICU and MICU providers were the same pool of caregivers, further supporting a process issue related to isolation precautions. Institutions should be aware of the need for extra attention to supply chain management and examination of disruption to standard work that arise in the management of COVID-19 patients.Disclosures All Authors: No reported disclosures

Single port robotic radical prostatectomy versus multi-port robotic radical prostatectomy: A human factor analysis during the initial learning curve.

Studies have thus far neglected to evaluate the impact of the da Vinci single port (SP) robotic platform on surgeon experience and operating room efficiency. We sought to assess the effect of the SP platform on surgeon cognitive load measures during robotic assisted laparoscopic prostatectomy (RALP). We prospectively compared the first 20 SP-RALPs performed at our institution to 20 multi-port (MP)-RALPs performed by a single experienced robotic surgeon. Three multi-dimensional assessment tools were used to evaluate mental and surgical workload, teamwork and workflow disruptions. No statistically significant differences were found between the MP-RALP and SP-RALP cohorts when evaluated by NASA Task Load Index, Surgery Task Load Index and Observational Teamwork Assessments. The SP robotic platform did not adversely affect human factor performance of the surgeon during RALP. Multi-institutional validation will be necessary to confirm these initial findings.

Using Innovation to Navigate Waves of COVID-19 Resurgence.

Using Innovation to Navigate Waves of COVID-19 Resurgence.

COVID-19 Pandemic: The Effects and Prospects in the Construction Industry

COVID-19, social distancing, self-isolation, quarantine, furlough, palliatives, and many more emerged as the new vocabularies of the entire world, construction industry not excluded. It is precisely a decade from the last pandemic experienced by the human race. However, the most popular disease outbreak called Corona Virus Disease 2019 (COVID-19) was announced, which hit all the nations of the world within four months and was declared a pandemic in March 2020. This outbreak disrupted businesses around the globe, including built asset procurement and facility management. The United Kingdom, through the Construction Leadership Council, for instance, in responding to this unprecedented situation, published a new Site Operating Procedure (SOP). The effect of this Pandemic in these extraordinary times posed both positive and negative impacts in the Architecture, Engineering and Construction, Owner and Operator (AECOO) industry. Its effect has brought about innovative and diverse use of technology in an exemplary manner which may change the course of construction even after the extinction of coronavirus. This study explores the effects of COVID-19 on the built asset procurement and potential opportunities for the construction industry through a quantitative means. A survey was carried out on the built asset procurement professionals for the data collection. 71 questionnaires were received from Architects, Building Engineers, Civil/Structural Engineers, Electrical Engineers, Mechanical Engineers, Construction / Project Managers and Quantity Surveyors. SPSS 25 software (a social science statistical package) was used for the analysis of the data. The result reveals some challenges in the area of workflow and supply chain disruption, new policy issues, workers’ anxiety and review of COVID-19 vs Force Majeure in standard forms of the construction contract. However, opportunities evolved in the field of modern procurement planning, the necessity for virtual working and unique design considerations. This study is essential to paving the way for the development of additional contingency plans and a new working strategy in a minimised human contact situation caused by the pandemic.

Assessment of Nonroutine Events During Intubation After Pediatric Trauma

BackgroundIntubation in the early postinjury phase can be a high-risk procedure associated with an increased risk of mortality when delayed. Nonroutine events (NREs) are workflow disruptions that can be latent safety threats in high-risk settings and may contribute to adverse outcomes. Materials and methodsWe reviewed videos of intubations of injured children (age<17 y old) in the emergency department occurring between 2014 and 2018 to identify NREs occurring between the decision to intubate and successful intubation (“critical window”). ResultsAmong 34 children requiring intubation, the indications included GCS≤8 (n = 20, 58.8%), cardiac arrest (n = 6, 17.6%), airway protection (n = 5, 14.7%), and respiratory failure (n = 3, 8.8%). The median duration of the “critical window” was 7.5 min (range 1.4-27.5 min), with a median of six NREs per case in this period (range 2-30). Most NREs (n = 159, 61.9%) delayed workflow, with 31 (12.1%) of these delays each lasting more than one minute. Eighty-seven NREs (33.9%) had a potential for harm but did not lead to direct patient harm. The most common NREs directly related to the intubation process were poor positioning for intubation (n = 23, 8.9%) and difficulty passing the endotracheal tube (n = 5, 1.9%), with most being attributed to the anesthesiologist performing the intubation (n = 51, range 0-7). ConclusionsWorkflow disruptions related to nonroutine events were frequent during pediatric trauma intubation and were often associated with delays and potential for patient harm. Interventions for improving the efficiency and timeliness of the critical window should focus on adherence to intubation protocol and improving communication and teamwork related to tasks in this phase.

Evaluating Errors and Inefficiencies in Brachytherapy: An Approach Toward Process Redesign and Patient Safety

Despite extensive literature on patient safety (PS) and operating room crew resource management, the intersection between critical events during brachytherapy (BT) and fundamentals of PS are not well described. Radiation oncology (RO) quality and safety are commonly approached from a physics and dosimetry perspective, creating a need to better understand issues impacting quality of care and safety in BT. This study uses a mixed-methods approach to incident analysis of PS events and process improvement (PI) opportunities, reported during BT, to identify and quantify errors, inefficiencies and workflow interruptions. The purpose is to describe the current landscape and allow for multidisciplinary development of adaptive interventions toward more efficient and safer BT practices. Safety reports [SR: PS events] and glitch logs [GL: PI opportunities], submitted by multidisciplinary team members, were retrospectively reviewed from a prospectively collected database at a large, tertiary cancer center providing high-volume BT services. The study spanned from 9/2014 - 12/2019. Events were quantified by patterns of occurrence. Review of SR/GL narratives were done to qualitatively analyze events for recurrent themes. A total of 2,455 patients received 7,606 fractions between 2014 and 2019. There were 105 events, accounting for 4.28% of all patients and 1.38% of all fractions (none were state/NRC reportable). Four predominant recurring themes were seen (Table 1): (1) equipment concerns (inappropriate use, failure, missing/broken), (2) human factors (poor communication, handoffs, cross coverage, unclear roles/responsibilities, training/experience), (3) workflow inefficiencies (scheduling, coordination, new processes, transport, room turnover) and (4) electronic documentation (software, planning, manual data entry, information transfer). Human factors were the most common category of events documented: SR (42.9%) and GL (37.1%). Number of events reported was higher from July through December in every year (in aggregate, these represented 70% of SR and 60% of GL). During reporting, two safety systems were put into place from sentinel events: (1) a checklist to prevent retained foreign objects and (2) a team checklist for high-risk significant bleeding following interstitial implant removal. In-depth evaluation of errors and inefficiencies by multidisciplinary teams in BT may lead to better understanding and implementation of PS procedures and PI strategies for BT delivery. Multidisciplinary teams are critical in providing perspectives for addressing common workflow issues and innovative solutions for patient care, with the potential for implementation at other BT capable institutions.Abstract 2449; TableEvent Characteristics & Predominant Themes by Category NumberPredominant Themes in SR/GLCombined Events n = 105119 (18.1%) [11.3%,26.8%]243 (41.0%) [31.5%,51.0%]328 (26.7%) [18.5%,36.2%]415(14.3%) [8.2%-22.5%] Open table in a new tab