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Research
Projects Human Error
in Naturalistic Medical Environments Cognition and Error Management in Critical Care (Funded by NLM. PI: Vimla
L. Patel, UT The core objective of this
research is to develop a cognitive framework of medical errors in critical
care environments (medicine, surgery and psychiatry), where decisions are
often made under high stress, time pressure, and with incomplete information. This theoretical framework provides two
functions: (1) a cognitive taxonomy of errors where each category of medical
error is associated with a specific cognitive mechanism,
and (2) a theoretical explanation of why these errors occur and
prediction of the circumstances in which such errors would occur. The studies
are being conducted in the adult medical and psychiatric emergency
departments, and in the cardio-thoracic intensive care unit. Using cognitive
science techniques, we have collected and analyzed data in these units, and
have developed decision making models of these complex environments.
Additional data collection and analysis is ongoing in the light of these
models. Last, a new unit has been added to the study, the pediatric emergency
department. Data collection and analysis in this unit will start in this unit
in the Summer of 2005. In our view human errors
are products of cognitive activities in people's adaptation to their complex
physical, social, and cultural environments. Our cognitive approach stresses
actions in conceptual understanding and thought processes during clinical
problem solving. The actions reflect the level of expertise and the demands
of tasks in clinical performance. In
order to manage errors during clinical decision-making, it is critical to
understand how decisions are made and what underlying cognitive mechanisms
are used to process information during interactions with patients,
colleagues, and technology in the critical-care environment. Unlike the popular goal of achieving
flawless performance (through development of error-free systems), the
empirical results from this study will be used to enhance and modify the
current, more static, error taxonomy and will guide development of adaptive
systems that anticipate errors, respond to them, or substitute less serious
errors that allow subsequent intervention before the errors result in an
adverse event. A
cognitive blueprint of collaboration in context: distributed cognition in the
Psychiatric Emergency Department Several months of observational data and interviews
with a representative sample of clinical staff have informed the development
of a model that captures the complex collaborative nature of work in the
psychiatric emergency department. Cognition in this environment is
distributed across multidisciplinary teams, as well as across time as the
members of the core clinical team change shifts. This process is further
complicated by the fact the information patients provide may be unreliable or
insufficient to support clinical care. Several latent flaws in this system
noted during the observation period were supported during the interview
process, and these have been mapped to our model. Based on this foundation,
audio-recordings of key clinical interactions were collected. Analysis of
these data has focused on the identification of incidents of error detection
and recovery during clinical rounds. Team: Trevor Cohen, Brett Blatter,
Carlos Almeida, Vimla Patel) Workflow
Modeling in Critical Care: Piecing Together Your Own Puzzle The intensive care unit (ICU) is an instance of a
very dynamic health care setting where critically ill patients are being
managed. To provide good care, an extensive and coordinated communication
amongst the role players, use of numerous information systems and operation
of devices for monitoring and treatment purposes are required. The purpose of
this research is to study error evolution and management within this
environment. The focus is on representing the workflow of critical care
environment, which emphasizes the importance such a representation may play
in strategizing the management of medical errors. We used ethnographic
observation and interview data to build individual pieces of the workflow,
dependent on the individual and the activity concerned. Key personnel were
intensively followed during their respective patient care activities and the
related actions. All interactions were recorded for analysis. These
clinicians and nurses were interviewed to complement the observation data and
to delineate their individual workflows. These pieces of the ICU workflow
were used to develop a generalize-able cognitive model to represent the
intricate workflow applicable to other health care settings. The proposed
model can be used to identify and characterize medical errors and for error
prediction in practice. Team: Sameer Malhotra, Desmond Jordon, Edward Shortliffe, Vimla Patel) Interruptions & Multitasking in Adult Emergency Department
Several studies have
shown that there is information loss during interruptions, and that
multitasking creates higher memory load, both of which contribute to medical
error. Nowhere is this more critical than in the Emergency department (ED),
where the emphasis of clinical decision is on the timely evaluation and
stabilization of patients. This paper reports on the nature of multitasking
and shift change and its implications for patient safety in an adult ED, using
the methods of ethnographic observation and interviews. Data were analyzed
using grounded theory to study cognition in the context of the work
environment. Analysis revealed that interruptions within the ED were
prevalent and diverse in nature. On average, there was an interruption every
nine minutes and 14 minutes for the attending physicians and the
residents respectively. In addition, the workflow analysis showed gaps in
information flow due to multitasking and shift changes. Transfer of
information began at the point of hand-offs/shift changes and continued
through various other activities, such as documentation, consultation,
teaching activities and utilization of computer resources. The results show
that the nature of the communication process in the ED is complex and
cognitively taxing for the clinicians, which can compromise patient safety. Team: Vimla Patel, Forogh
Hakimzhada, Archana Laxmisen, Jiajie Zhang, Robert
Green and Ozman Sayan Triage Decision-Making in the ER As the first step in the assessment of emergency
department patients, triage plays an important role in categorizing and
prioritizing patients correctly and efficiently according to their medical
condition. Guidelines are used in these emergency situations such that triage decisions are standardized.
However, these guidelines are not often used at the point of care. This study
investigates how triage decisions are made as well as the role of triage
guidelines in such decision-making. Using observations, and semi-structured
interviews of triage nurses, data was collected in the pediatric emergency
department of a large teaching hospital. Results show that: 1) triage
decisions were non-analytic and based on intuition and experience, especially
in high urgency situation, 2) situational factors such as busyness of ED, use
of technology, and language barriers affect the triage process and 3)
Guidelines were not used during the triage process. Hospitals transitioning
from paper to electronic information systems often find inadequate fit
between newly implemented technology and work environment causing delays,
inefficient use of resources and new kind of errors attributable to problems
in human interaction with computer systems. The purpose of this study was to
characterize the workflow, decision-making and cognitive processing of
clinicians in the process of care in emergency department of a large urban
hospital and to suggest possible technological interventions for identified
problem areas. The task begins with the process of pre-triage and triage.
Through the analysis of collected data we identified fifteen tasks and areas
that either slowed work progress by unnecessary duplication or created
potential for error generation. Recommendations are made for the replacement
of currently inadequate or non-existent technology support of clinicians by
information and communication technology specifically selected to fit the
cognitive and workflow demands of the task. Team: Vimla L. Patel, Jan
Horsky, Lily Gutnik,
Cornelia Williams Staffing and shift change: A Work Flow
analysis in the Pediatric Emergency Department. The Pediatric Emergency Department is a unique
environment, since clinicians are dealing with young patients and there is a
need for the participation of parents and even other relatives. Through
cognitive approaches, we will study the mechanisms and actions involved in
the clinician decision making process; underline the procedures that are used
to process information during interactions between clinicians and patients,
as well as interactions with their parents or other relatives. We have just
completed the ethnographic component of the study and have developed a
workflow model; these studies will enhance the overall theoretical model in
critical care and the practical goals of Pediatric ER. Team: Eneida A Mendonça,David Teng, Saroja Hanasoge, Meridith Sonnett, Vimla Patel)
Collection and analysis of medical error data from
public sources Medical
error cases were collected from publicly available data sources in order to
provide preliminary data for the development of the cognitive taxonomy. Since
the first data source, the databases on medical device errors maintained by
U.S. Food and Drug Administration (FDA), has already been examined in one of
our preliminary studies (Brixey, Johnson, & Zhang, 2004), we have
explored some other public data sources such as MEDLINE®, newspapers,
web search engines and other sources. An initial search on MEDLINE®
(PubMed) was conducted to get an idea on the frequencies of medical errors
for the categories in the task-based taxonomy. This was followed by specific
searches on certain areas of medical errors. Analysis of some of the cases
retrieved through these searches revealed useful keywords that could be used
for further refining of the search strategy. Development
of a Comprehensive Medical Error Ontology (MEDEON) In order to analyze and interpret the medical error cases, data from
various sources were collected, and a comprehensive medical error ontology
(MEDEON) was developed. MEDEON serves as a standard representation of medical
error related concepts and relationships.
MEDEON was developed using an integration-based development approach
which involved re-using knowledge from existing relevant taxonomies in
literature by (1) merging individual taxonomies to create a reference
ontology, and (2) mapping the reference ontology with the original taxonomies
to produce the end-product. Following a literature review of existing and
published taxonomies related to medical errors, eight candidate taxonomies
were selected. The taxonomies were modeled as ontologies in Protégé-OWL, and
then aligned with one another through identification of semantic relations
between concepts contained in the source ontologies. Once aligned, the source
ontologies were merged to produce a single reference
ontology with 12 multi-dimensional axes, the intersection of which,
characterizes a medical error event. The classes and relationships in the
reference ontology were implemented using Protégé-OWL. Care studies: Taxonomy of interruption-related
medical errors in Emergency Department An observational study continues to study workflow
and interruptions for doctors and nurses working in a |
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