Objective To compare the incidence, severity, preventability, and contributing factors of non-routine events— deviations from optimal care based on the clinical situation —associated with team-based, nurse-to-nurse, and mixed handovers in a large cohort of surgical neonates. Study design A prospective observational study and one-time cross-sectional provider survey were conducted at one urban academic children’s hospital. 130 non-cardiac surgical cases in 109 neonates who received pre- and post-operative NICU care. Results The incidence of clinician-reported NREs was high (101/130 cases, 78%) but did not differ significantly across acuity-tailored neonatal handover practices. National Surgical Quality Improvement—Pediatric occurrences of major morbidity were significantly higher ( p < 0.001) in direct team handovers than indirect nursing or mixed handovers. Conclusions NREs occur at a high rate and are of variable severity in neonatal perioperative care. NRE rates and contributory factors were homogenous across handover types. Surveyed clinicians recommend structured handovers for all patients at every transfer point regardless of acuity.

Patient safety is a cornerstone of high quality cancer care. However, current efforts rely on clinician-centric methods. In this IRB-approved pilot study, we evaluated the feasibility of an innovative approach to prospectively capture system safety data using patient-reported non-routine events (PNREs), defined as events that deviate from expected/optimal care. We postulated that safety-related PNREs will identify potential flaws in cancer care pathways that increase the likelihood of unplanned treatment events/errors (UTEs) and lower standardized experience measures. Eligibility included ECOG 0-2 adult patients with newly diagnosed head/neck & lung cancer scheduled to receive curative radiation (RT). PNREs, using our previously validated Patient-reported Comprehensive Open-ended Non-routine Event Survey (PCONES) tool, and patient-reported experience measures including: the EORTC-QLQ-30 (to compute a Global Health Status (GHS) on a 0-100 scale), the NCCN Distress Thermometer (DT, 0-10 scale), and 4 core ambulatory Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey questions, were collected at each on-treatment visit. Additionally, physicians completed the NCI CTCAE v4.0 toxicity score and collected UTEs from the patients' medical records. Propensity score weighting and regression methods were used to quantify associations between PNREs and patient experience. 20/24 patients (pts) who enrolled with 2 months f/u during RT comprise our study cohort. Mean age was 64.5±2.1 year (SEM); 60% male. Overall, 80 encounters occurred, median of 4 (range: 3-5). In 39% of encounters, at least one PNRE was reported yielding 40 total PNREs from 75% of the pts. 32.5% of PNREs were safety related while the remaining were related to pts' care experience. In encounters when pts did not report PNREs, the GHS and DT measurements were 70.8±3.0 and 2.5±0.4, respectively. In cases where pts reported at least one PNRE, GHS decreased to 63.9±4.4 (p=0.182) and distress increased to 3.7±0.6 (p=0.088). The GHS was even lower (56.4±6.9) and distress higher (4.6±0.9) in pts who experienced safety-related PNREs. Three study pts each had one UTE (15% of participants), including a hospital readmission for surgical complications. 15.4% of the adult safety-related PNREs related to these UTEs. The 5 pts who never reported a PNRE experienced no UTEs. Encounters in which PNREs were reported were associated with lower CAHPS composite scores – no PNRE: 58% top-box ratings; ≥1 PNRE: 19% top-box ratings (p<0.001). This pilot study demonstrates the feasibility of collecting PNREs to identify potential systems safety risks in a radiation oncology clinic. Future efforts will include a large phase II trial to validate these findings, and to assess the value of PNREs in improving cancer care processes and patients' outcomes.

This paper reports the results of an evaluation of a computer-based protocol for managing patient blood glucose. The computerized protocol, having proven successful in the Surgical ICU, was implemented in the Trauma ICU. Five nurses in the Trauma ICU were interviewed and observed while using the computer-based protocol for blood glucose management. Results of the evaluation indicated that while the computerized features, such as the calculation of insulin drip rate and patient chart scanning, were helpful, nurses were spending more time and energy than before computerization to manage patient blood glucose, and that the computerized recommended treatments were often inappropriate due to the unique patient population. Suggestions for modification of the protocol to accommodate the different patient population and needs of the Trauma ICU are provided. Also, a usability test before the implementation of the new design and a follow-up assessment soon after implementation are highly recommended.

Experience from other domains suggests that videotaping and analyzing actual clinical care can provide valuable insights for enhancing patient safety through improvements in the process of care. Methods are described for the videotaping and analysis of clinical care using a high quality portable multi-angle digital video system that enables simultaneous capture of vital signs and time code synchronization of all data streams. An observer can conduct clinician performance assessment (such as workload measurements or behavioral task analysis) either in real time (during videotaping) or while viewing previously recorded videotapes. Supplemental data are synchronized with the video record and stored electronically in a hierarchical database. The video records are transferred to DVD, resulting in a small, cheap, and accessible archive. A number of technical and logistical issues are discussed, including consent of patients and clinicians, maintaining subject privacy and confidentiality, and data security. Using anesthesiology as a test environment, over 270 clinical cases (872 hours) have been successfully videotaped and processed using the system.

To enhance patient safety, data about actual clinical events must be collected and scrutinized. This paper has two purposes. First, it provides an overview of some of the methods available to collect and analyze retrospective data about medical errors, near misses, and other relevant patient safety events. Second, it introduces a methodological approach that focuses on non-routine events (NRE), defined as all events that deviate from optimal clinical care. In intermittent in-person surveys of anesthesia providers, 75 of 277 (27%) recently completed anesthetic cases contained a non-routine event (98 total NRE). Forty-six of the cases (17%) had patient impact while only 20 (7%) led to patient injury. In contrast, in the same hospitals over a two-year period, we collected event data on 135 cases identified with traditional quality improvement processes (event incidence of 0.7–2.7%). In these quality improvement cases, 120 (89%) had patient impact and 74 (55%) led to patient injury. Preliminary analyses not only illustrate some of the analytical methods applicable to safety data but also provide insight into the potential value of the non-routine event approach for the early detection of risks to patient safety before serious patient harm occurs.

Objective To determine the percentage of time that intensive care unit (ICU) nurses spend on documentation and other nursing activities before and after installation of a third-generation ICU information system. Design Prospective data collection using real-time time-motion analysis, before and after installation of the ICU information system. Setting A ten-bed surgical ICU at a Veterans Affairs medical center. Subjects ICU nurses. Interventions Installation of a third-generation ICU information system. Measurements and Main Results Ten ICU nurses were studied before and after installation of the ICU information system. Each ICU nurse's activities and tasks, during 4-hr observation periods, were categorized in real-time by a nurse observer and recorded in a laptop computer. Each recorded task was automatically time-stamped and logged into a data file. The percentage of time spent on documentation decreased from 35.1 ± 8.3% to 24.2 ± 7.6% (p = .025) after the ICU information system was installed. The percentage of time providing direct patient care increased from 31.3 ± 9.2% to 40.1 ± 11.7% (p = .085). The percentage of time doing patient assessment, a direct patient care task, increased from 4.0 ± 4.7% to 9.4 ± 4.4% (p = .001). Conclusions Installation of a third-generation ICU information system decreased the percentage of time ICU nurses spent on documentation by >30%. Almost half of the time saved on documentation was spent on patient assessment, a direct patient care task.

Background Task analysis may be useful for assessing how anesthesiologists alter their behavior in response to different clinical situations. In this study, the authors examined the intraobserver and interobserver reliability of an established task analysis methodology. Methods During 20 routine anesthetic procedures, a trained observer sat in the operating room and categorized in real-time the anesthetist's activities into 38 task categories. Two weeks later, the same observer performed task analysis from videotapes obtained intraoperatively. A different observer performed task analysis from the videotapes on two separate occasions. Data were analyzed for percent of time spent on each task category, average task duration, and number of task occurrences. Rater reliability and agreement were assessed using intraclass correlation coefficients. Results Intrarater reliability was generally good for categorization of percent time on task and task occurrence (mean intraclass correlation coefficients of 0.84-0.97). There was a comparably high concordance between real-time and video analyses. Interrater reliability was generally good for percent time and task occurrence measurements. However, the interrater reliability of the task duration metric was unsatisfactory, primarily because of the technique used to capture multitasking. Conclusions A task analysis technique used in anesthesia research for several decades showed good intrarater reliability. Off-line analysis of videotapes is a viable alternative to real-time data collection. Acceptable interrater reliability requires the use of strict task definitions, sophisticated software, and rigorous observer training. New techniques must be developed to more accurately capture multitasking. Substantial effort is required to conduct task analyses that will have sufficient reliability for purposes of research or clinical evaluation.

Patient safety has become a major public concern. Human factors research in other high-risk fields has demonstrated how rigorous study of factors that affect job performance can lead to improved outcome and reduced errors after evidence-based redesign of tasks or systems. These techniques have increasingly been applied to the anesthesia work environment. This paper describes data obtained recently using task analysis and workload assessment during actual patient care and the use of cognitive task analysis to study clinical decision making. A novel concept of "non-routine events" is introduced and pilot data are presented. The results support the assertion that human factors research can make important contributions to patient safety. Information technologies play a key role in these efforts.