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Teams and Cardiac Surgery

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9th Bi-annual International Conference on Naturalistic Decision Making (NDM9) (NDM)

Naturalistic Decision Making (NDM9)

23 - 26 June 2009

Medical errors, patient safety, medical teams

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      Abstract

      Motivation – Our study is designed to identify human factors that are a threat to the safety of children with heart disease. Research approach – After an initial observation period, we will apply a major safety intervention. We will then re-measure the occurrence and types of human factors in the operating room, and the incidence of adverse events, near misses and hospital death, to evaluate if there was a significant post-intervention reduction. Findings/design – We focus on challenges encountered during the training of the observers. Research Limitations – Because of the complexity of the OR, observations are necessarily subjective. Originality/Value – This work is original because of the systematic evaluation of a safety intevention and the training protocol for the observers. Take Away Message – Systematic and periodic assessment of observers is required when teamwork is observed in complex, dynamic settings.

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      Most cited references 28

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      Organizational change and development.

      Recent analyses of organizational change suggest a growing concern with the tempo of change, understood as the characteristic rate, rhythm, or pattern of work or activity. Episodic change is contrasted with continuous change on the basis of implied metaphors of organizing, analytic frameworks, ideal organizations, intervention theories, and roles for change agents. Episodic change follows the sequence unfreeze-transition-refreeze, whereas continuous change follows the sequence freeze-rebalance-unfreeze. Conceptualizations of inertia are seen to underlie the choice to view change as episodic or continuous.
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        On error management: lessons from aviation.

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          A look into the nature and causes of human errors in the intensive care unit.

           R Pizov,  C Sprung,  Y Donchin (1995)
          The purpose of this study was to investigate the nature and causes of human errors in the intensive care unit (ICU), adopting approaches proposed by human factors engineering. The basic assumption was that errors occur and follow a pattern that can be uncovered. Concurrent incident study. Medical-surgical ICU of a university hospital. Two types of data were collected: errors reported by physicians and nurses immediately after an error discovery; and activity profiles based on 24-hr records taken by observers with human engineering experience on a sample of patients. During the 4 months of data collection, a total of 554 human errors were reported by the medical staff. Errors were rated for severity and classified according to the body system and type of medical activity involved. There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day. A significant number of dangerous human errors occur in the ICU. Many of these errors could be attributed to problems of communication between the physicians and nurses. Applying human factor engineering concepts to the study of the weak points of a specific ICU may help to reduce the number of errors. Errors should not be considered as an incurable disease, but rather as preventable phenomena.
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            Author and article information

            Affiliations
            TNO Human Factors
            New South Wales Injury Risk Management Center
            TNO Quality of Life
            Contributors
            Conference
            June 2009
            June 2009
            : 152-159
            10.14236/ewic/NDM2009.14
            © Jan Maarten Schraagen et al. Published by BCS Learning and Development Ltd. 9th Bi-annual International Conference on Naturalistic Decision Making (NDM9), BCS London

            This work is licensed under a Creative Commons Attribution 4.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

            9th Bi-annual International Conference on Naturalistic Decision Making (NDM9)
            NDM
            9
            BCS London
            23 - 26 June 2009
            Electronic Workshops in Computing (eWiC)
            Naturalistic Decision Making (NDM9)
            Product
            Product Information: 1477-9358 BCS Learning & Development
            Self URI (journal page): https://ewic.bcs.org/
            Categories
            Electronic Workshops in Computing

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