The goal of the study was to develop an in-depth understanding of work practices, workflow, and information flow in chronic disease care, to facilitate development of context-appropriate informatics ...tools.
The study was conducted over a 10-month period in three ambulatory clinics providing chronic disease care. The authors iteratively collected data using direct observation and semi-structured interviews.
The authors observed all aspects of care in three different chronic disease clinics for over 150 hours, including 157 patient-provider interactions. Observation focused on interactions among people, processes, and technology. Observation data were analyzed through an open coding approach. The authors then developed models of workflow and information flow using Hierarchical Task Analysis and Soft Systems Methodology. The authors also conducted nine semi-structured interviews to confirm and refine the models.
The study had three primary outcomes: models of workflow for each clinic, models of information flow for each clinic, and an in-depth description of work practices and the role of health information technology (HIT) in the clinics. The authors identified gaps between the existing HIT functionality and the needs of chronic disease providers.
In response to the analysis of workflow and information flow, the authors developed ten guidelines for design of HIT to support chronic disease care, including recommendations to pursue modular approaches to design that would support disease-specific needs. The study demonstrates the importance of evaluating workflow and information flow in HIT design and implementation.
Abstract
Purpose
To analyze the clinical completeness, correctness, usefulness, and safety of chatbot and medication database responses to everyday inpatient medication-use questions.
Methods
We ...evaluated the responses from an artificial intelligence chatbot, a medication database, and clinical pharmacists to 200 real-world medication-use questions. Answer quality was rated by a blinded group of pharmacists, providers, and nurses. Chatbot and medication database responses were deemed “acceptable” if the mean reviewer rating was within 3 points of the mean rating for pharmacists’ answers. We used descriptive statistics for reviewer ratings and Kendall’s coefficient to evaluate interrater agreement.
Results
The medication database generated responses to 194 (97%) questions, with 88% considered acceptable for clinical correctness, 76% considered acceptable for completeness, 83% considered acceptable for safety, and 81% considered acceptable for usefulness compared to pharmacists’ answers. The chatbot responded to only 160 (80%) questions, with 85% considered acceptable for clinical correctness, 65% considered acceptable for completeness, 71% considered acceptable for safety, and 68% considered acceptable for usefulness.
Conclusion
Traditional search methods using a drug database provide more clinically correct, complete, safe, and useful answers than a chatbot. When the chatbot generated a response, the clinical correctness was similar to that of a drug database; however, it was not rated as favorably for clinical completeness, safety, or usefulness. Our results highlight the need for ongoing training and continued improvements to artificial intelligence chatbots for them to be incorporated reliably into the clinical workflow. With continued improvement in chatbot functionality, chatbots could be a useful pharmacist adjunct, providing healthcare providers with quick and reliable answers to medication-use questions.
Highlights • Post-EHR, all physicians spent more time on clinical review and documentation. • Residents switched tasks more often after EHR implementation, attendings less. • Temporal flow of tasks ...changed after EHR implementation. • No changes observed in conversation or physical care of the patient.
Highlights ► Nurses found the integrated graphical display more usable than their current hospital system. ► Performance improved using the graphical display only at the primary design institution. ► ...Medical information displays optimized for use at one clinical site may not be as favorable for other clinical sites. ► Health information technology needs to be flexible and configurable to meet local design constraints.
•The measurement of non-routine events (NRE) is a safety methodology arising from the field of human factors engineering and is meant to detect potential safety alarms well upstream of an adverse ...event (e.g., NSQIP-P occurrence).•The NRE methodology has never been applied to neonatal surgery, which was our goal. To simplify this pilot study, we applied NRE measurement to G-tube placement in the NICU surgical population.•We found that even in this "simple" operative procedure >80% of cases had an NRE reported by involved clinicians whereas only 19% had a NSQIP-P occurrence reported.•NRE occurrence was not associated with an increased likelihood of an NSQIP-P occurrence, but this methodology does offer novel information that should be considered as we try to increase surgical safety.•Application of this methodology to a broader array of operative procedures is needed.
Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement.
A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube.
Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06–17.04).
Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations.
IV
BACKGROUND:Failures of communication are a major contributor to perioperative adverse events. Transitions of care may be particularly vulnerable. We sought to improve postoperative handovers.
...METHODS:We introduced a multimodal intervention in an adult and a pediatric postanesthesia care unit (PACU) to improve postoperative handovers between anesthesia providers (APs) and PACU registered nurses (RNs). The intervention included a standardized electronic handover report form, a didactic webinar, mandatory simulation training focused on improving interprofessional communication, and post-training performance feedback. Trained, blinded nurse observers scored PACU handovers during 17 months using a structured tool consisting of 8 subscales and a global score (1–5 scale). Multivariate logistic regression assessed the effect of the intervention on the proportion of observed handovers receiving a global effectiveness rating of ≥3.
RESULTS:Four hundred fifty-two clinicians received the simulation-based training, and 981 handovers were observed and rated. In the adult PACU, the estimated percentages of acceptable handovers (global ratings ≥3) among AP-RN pairs, where neither received simulation-based training (untrained dyads), was 3% (95% confidence interval, 1%–11%) at day 0, 10% (5%–19%) at training initiation (day 40), and 57% (33%–78%) at 1-year post-training initiation (day 405). For AP-RN pairs where at least one received the simulation-based training (trained dyads), these percentages were estimated to be 18% (11%–28%) and 68% (57%–76%) on days 40 and 405, respectively. The percentage of acceptable handovers was significantly greater on day 405 than it was on day 40 for both untrained (P < 0.001) and trained dyads (P < 0.001). Similar patterns were observed in the pediatric PACU. Three years later, the unadjusted estimate of the probability of an acceptable handover was 87% (72%–95%) in the adult PACU and 56% (40%–72%) in the pediatric PACU.
CONCLUSIONS:A multimodal intervention substantially improved interprofessional PACU handovers, including those by clinicians who had not undergone formal simulation training. An effect appeared to be present >3 years later.
BACKGROUNDMedication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse’s medication management—especially ...medication-related events (MREs)—provides an approach to analyze and improve medication safety and quality.
OBJECTIVESThe goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses’ work in the ICUs.
METHODSWe conducted 124 structured 4-hour observations of nurses in three different ICUs. Each observation included measurement of nurse’s moment-to-moment activity and self-reports of workload and negative mood. The observer then obtained MRE reports from the nurse using a structured tool. The MREs were analyzed by three experts.
RESULTSMREs were reported in 35% of observations. The 60 total MREs included four medication errors and seven adverse drug events. Of the 49 remaining MREs, 65% were associated with negative patient impact. Task/process deficiencies were the most common contributory factor for MREs. MRE occurrence was correlated with increased total task volume. MREs also correlated with increased workload, especially during night shifts.
DISCUSSIONMost of these MREs would not be captured by traditional event reporting systems. Facilitated MRE reporting provides a robust information source about potential breakdowns in medication management safety and opportunities for system improvement.
Audible alarms are a ubiquitous feature of all high-paced, high-risk domains such as aviation and nuclear power where operators control complex systems. In such settings, a missed alarm can have ...disastrous consequences. It is conventional wisdom that for alarms to be heard, "louder is better," so that alarm levels in operational environments routinely exceed ambient noise levels. Through a robust experimental paradigm in an anechoic environment to study human response to audible alerting stimuli in a cognitively demanding setting, akin to high-tempo and high-risk domains, clinician participants responded to patient crises while concurrently completing an auditory speech intelligibility and visual vigilance distracting task as the level of alarms were varied as a signal-to-noise ratio above and below hospital background noise. There was little difference in performance on the primary task when the alarm sound was -11 dB below background noise as compared with +4 dB above background noise-a typical real-world situation. Concurrent presentation of the secondary auditory speech intelligibility task significantly degraded performance. Operator performance can be maintained with alarms that are softer than background noise. These findings have widespread implications for the design and implementation of alarms across all high-consequence settings.
Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, ...identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.
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