Around the Patient Bed: Human Factors and Safety in Health Care

338 Pages·2013·24.42 MB·English

by  Yoel Donchin

ERGONOMICS AND HUMAN FACTORS D
AROUND
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the
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AROUND I
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| G PATIENT BED
PATIENT BED O
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HUMAN FACTORS AND SAFETY IN HEALTH CARE
HUMAN FACTORS AND SAFETY
The occurrence of failures and mistakes in health care, from primary care procedures to the
IN HEALTH CARE
complexities of the operating room, has become a hot-button issue with the general public A
and within the medical community. Around the Patient Bed: Human Factors and Safety in
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Health Care examines the problem and investigates the tools to improve health care quality
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and safety from a human factors engineering viewpoint—the applied scientific field engaged
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in the interaction between the human operator (functionary, worker), task requirements, the
governing technical systems, and the characteristics of the work environment. N
D
The book presents a systematic human factors based, proactive approach to the improvement
of health care work and patient safety. The proposed approach delineates a more direct and
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powerful alternative to the contemporary dominant focus on error investigation and care h
e
providers’ accountability. It demonstrates how significant improvements in the quality of care

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and enhancement of patient safety are contingent on a major shift from efforts and investments
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driven by a retroactive study of errors, incidents, and adverse events, to an emphasis
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on proactive human factors driven intervention and the development of corresponding
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conceptual approaches and methods for its systematic implementation.
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N
Edited by Yoel Donchin, representing the medical profession, and Daniel Gopher, from the
human factors engineering field, the book brings together experts who have collaborated to T
present studies that reveal a wide range of problems and weaknesses of the contemporary
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health care system, which impair safety and quality and increase workload. The book
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presents practical solutions based on human factors engineering components and cognitive
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psychology, and explains their driving principles and methodologies. This approach provides
tools to significantly reduce the number of errors, create a safe environment, and improve the
quality of health care.
YOEL DONCHIN
EDITED BY
K16660 DANIEL GOPHER
6000 Broken Sound Parkway, NW
Suite 300, Boca Raton, FL 33487
711 Third Avenue
New York, NY 10017
an informa business
2 Park Square, Milton Park
www.crcpress.com Abingdon, Oxon OX14 4RN, UK www.crcpress.com
AROUND
the
PATIENT BED
HUMAN FACTORS AND SAFETY
IN HEALTH CARE
Human Factors and Ergonomics Series
Published TiTles
Around the Patient Bed: Human Factors and Safety in Health Care
Y. Donchin and D. Gopher
Conceptual Foundations of Human Factors Measurement
D. Meister
Content Preparation Guidelines for the Web and Information Appliances:
Cross-Cultural Comparisons
H. Liao, Y. Guo, A. Savoy, and G. Salvendy
Cross-Cultural Design for IT Products and Services
P. Rau, T. Plocher and Y. Choong
Data Mining: Theories, Algorithms, and Examples
Nong Ye
Designing for Accessibility: A Business Guide to Countering Design Exclusion
S. Keates
Handbook of Cognitive Task Design
E. Hollnagel
The Handbook of Data Mining
N. Ye
Handbook of Digital Human Modeling: Research for Applied Ergonomics
and Human Factors Engineering
V. G. Duffy
Handbook of Human Factors and Ergonomics in Health Care and Patient Safety
Second Edition
P. Carayon
Handbook of Human Factors in Web Design, Second Edition
K. Vu and R. Proctor
Handbook of Occupational Safety and Health
D. Koradecka
Handbook of Standards and Guidelines in Ergonomics and Human Factors
W. Karwowski
Handbook of Virtual Environments: Design, Implementation, and Applications
K. Stanney
Handbook of Warnings
M. Wogalter
Human–Computer Interaction: Designing for Diverse Users and Domains
A. Sears and J. A. Jacko
Human–Computer Interaction: Design Issues, Solutions, and Applications
A. Sears and J. A. Jacko
Human–Computer Interaction: Development Process
A. Sears and J. A. Jacko
Human–Computer Interaction: Fundamentals
A. Sears and J. A. Jacko
The Human–Computer Interaction Handbook: Fundamentals
Evolving Technologies, and Emerging Applications, Third Edition
A. Sears and J. A. Jacko
Published TiTles (conTinued)
Human Factors in System Design, Development, and Testing
D. Meister and T. Enderwick
Introduction to Human Factors and Ergonomics for Engineers, Second Edition
M. R. Lehto
Macroergonomics: Theory, Methods and Applications
H. Hendrick and B. Kleiner
Practical Speech User Interface Design
James R. Lewis
The Science of Footwear
R. S. Goonetilleke
Skill Training in Multimodal Virtual Environments
M. Bergamsco, B. Bardy, and D. Gopher
Smart Clothing: Technology and Applications
Gilsoo Cho
Theories and Practice in Interaction Design
S. Bagnara and G. Crampton-Smith
The Universal Access Handbook
C. Stephanidis
Usability and Internationalization of Information Technology
N. Aykin
User Interfaces for All: Concepts, Methods, and Tools
C. Stephanidis
ForThcoming TiTles
Cognitive Neuroscience of Human Systems Work and Everyday Life
C. Forsythe and H. Liao
Computer-Aided Anthropometry for Research and Design
K. M. Robinette
Handbook of Human Factors in Air Transportation Systems
S. Landry
Handbook of Virtual Environments: Design, Implementation
and Applications, Second Edition,
K. S. Hale and K M. Stanney
Variability in Human Performance
T. Smith, R. Henning, and M. Wade

AROUND
the
PATIENT BED
HUMAN FACTORS AND SAFETY
IN HEALTH CARE
YOEL DONCHIN
DANIEL GOPHER
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
Book was previously published in Hebrew by Carta Jerusalem.
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2014 by Taylor & Francis Group, LLC
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Version Date: 20130812
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Contents
Preface.......................................................................................................................xi
The Editors .............................................................................................................xiii
Contributors .............................................................................................................xv
Chapter 1 Human Factors and Safety in Health Care ...........................................1
Daniel Gopher
Chapter 2 A History of Medical Errors ..............................................................13
Yoel Donchin
Chapter 3 Types and Causes of Medical Errors in Intensive Care .....................23
Daniel Gopher and Yoel Donchin
Chapter 4 The Operating Room and Operating Process—Observations ...........29
Yael Einav and Daniel Gopher
Chapter 5 Mental Models as a Driving Concept for the Analysis of Team
Performance in the Emergency Medicine Department ......................55
Shay Ben- Barak and Daniel Gopher
Chapter 6 Magnesium Sulphate Dosage—Analysis of Problems Involved
in the Medication Administration Process .........................................79
Efrat K edmi Shahar and Yael Einav
Chapter 7 Human Engineering and Safety Aspects in Neonatal Care
Units: Analysis and Appraisal ............................................................95
Yael A uerbach-Shpak, Efrat Kedmi Shahar, and Sivan Kramer
Chapter 8 Applying the Principles of Human– Computer Interaction to
Improve the Efficiency of the Emergency Medicine Unit ................119
Nirit Gavish
Chapter 9 Human Factors Contributions to the Design of a Medication Room ...131
Zvi Straucher
vii
© 2010 Taylor & Francis Group, LLC
viii Contents
Chapter 10 The User- Centered Design of a Radiotherapy Chart .......................139
Roni Sela and Yael Auerbach- Shpak
Chapter 11 Examining the Effectiveness of Using Designed Stickers
for Labeling Drugs and Medical Tubing ..........................................163
Dorit Sheffi, Yoel Donchin, Nurit Porat, and Yuval Bitan
Chapter 12 The Emperor’s New Clothes—Design of Garments for the
Operating Room Staff ......................................................................175
Anna Becker
Chapter 13 Thinking Patterns of Physicians and Nurses and the
Communication between Them in the Intensive Care Unit .............195
Yehuda Badihi and Daniel Gopher
Chapter 14 The Operating Room Briefing ..........................................................207
Yael Einav, Yoel Donchin, and Daniel Gopher
Chapter 15 Analysis of the Rate of Interruptions during Physician Rounds ......217
Yoel Donchin and Meirav Fogel
Chapter 16 How Does Risk Management Differ from Accident Prevention? ....229
Yoel Donchin
Chapter 17 Reconstruction to Investigate the Sources of an Event in a
Medical System ................................................................................235
Yoel Donchin
Chapter 18 Development of a Human Factor Focused Reporting System for
Hospital Medical Staff on Daily Difficulties and Problems in
Carrying Out Their Work .................................................................245
Ido Morag and Daniel Gopher
Chapter 19 Patient Safety Climate: Development of a Valid Scale to Predict
Safety Levels in Hospital Departments ............................................263
Yael Livne and Dov Zohar
© 2010 Taylor & Francis Group, LLC
Contents ix
Chapter 20 Beyond Fatigue: Managerial Factors Related to Resident
Physicians’ Medical Errors ..............................................................285
Zvi Stern, Eitan Naveh, and Tal K atz- Navon
Chapter 21 Gentle Rule Enforcement .................................................................293
Ido Erev and Dotan Rodensky
Chapter 22 Human Engineering and Safety in Health Care Systems—What
Have We Learned? ...........................................................................299
Daniel Gopher
Chapter 23 Summary: The Physician’s Point of View ........................................313
Yoel Donchin
© 2010 Taylor & Francis Group, LLC