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Poorly designed and implemented medication labels have been identified as a source of medication errors within anesthesia delivery. Previous studies noted that simplified text and icons are useful in warning labels used for prescription drugs, especially for people with low literacy levels. In addition, Tallman lettering can reduce errors due to the custom capitalization of text. However, icons, color, and Tallman lettering have not been explored for improving the readability of anesthesia medication labels. This study utilizes a user- centered approach to design and evaluate icons and other graphical features to be included on secondary medication labels placed on infusion bags within anesthesia point-of-care. The study utilizes an iterative design process to examine the potential efficacy of these design characteristics by evaluating them with the anesthesia providers/clinicians through an online survey. Findings suggest that introducing graphical components like icons and color may be useful and accepted by clinicians to improve medication recognition.

BACKGROUND: The introduction of new technology into the operating room (OR) can be beneficial for patients, but can also create new problems and complexities for physicians and staff. The observation of flow disruptions (FDs)—small deviations from the optimal course of care—can be used to understand how systems problems manifest. Prior studies showed that the docking process in robotic assisted surgery (RAS), which requires careful management of process, people, technology and working environment, might be a particularly challenging part of the operation. We sought to explore variation across multiple clinical sites and procedures; and to examine the sources of those disruptions. METHODS: Trained observers recorded FDs during 45 procedures across multiple specialties at three different hospitals. The rate of FDs was compared across surgical phases, sites, and types of procedure. A work-system flow of the RAS docking procedure was used to determine which steps were most disrupted. RESULTS: The docking process was significantly more disrupted than other procedural phases, with no effect of hospital site, and a potential interaction with procedure type. Particular challenges were encountered in room organization, retrieval of supplies, positioning the patient, and maneuvering the robot. CONCLUSIONS: Direct observation of surgical procedures can help to identify approaches to improve the design of technology and procedures, the training of staff, and configuration of the OR environment, with the eventual goal of improving safety, efficiency and teamwork in high technology surgery.

Medication errors and error-related scenarios in anesthesia remain an important area of research. Interventions and best practice recommendations in anesthesia are often based in the work-as-imagined healthcare system, remaining under-used due to a range of unforeseen complexities in healthcare work-as- done. In order to design adaptable anesthesia medication delivery systems, a better understanding of clinical cognition within the context of anesthesia work is needed. Fourteen interviews probing anesthesia providers’ decision making were performed. The results revealed three overarching themes: (1) anesthesia providers find cases challenging when they have incomplete information, (2) decision-making begins with information seeking, and (3) attributes such as expertise, experience, and work environment influence anesthesia providers’ information seeking and synthesis of tasks. These themes and the context within this data help create a more realistic view of work-as-done and generate insights into what potential medication error reducing interventions should look to avoid and what they could help facilitate.

Misreading labels, syringes, and ampoules is reported to make up a 54.4% of medication administration errors. The addition of icons to medication labels in an operating room setting could add additional visual cues to the label, allowing for improved discrimination, visibility, and easily processed information that might reduce medication administration errors. A multi-disciplinary team proposed a method of enhancing visual cues and visibility of medication labels applied to vasoactive medication infusions by adding icons to the labels. Participants were 1.12 times more likely to correctly identify medications from farther away (p < 0.001, AOR = 1.12, 95% CI: 1.02, 1.22) with icons. When icons were present, participants were 2.16 times more likely to be more confident in their identifications (p < 0.001, AOR = 2.16, 95%CI: 1.80, 2.57). Carefully designed icons may offer an additional method for identifying medications, and thus reducing medication administration errors.

Objective Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice. Background New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes. Results Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system. Conclusion There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care. Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

Direct observation is valuable for identifying latent threats and elucidating system complexity in clinical environments. This approach facilitates prospective risk assessment and reveals workarounds, near-misses and recurrent safety problems difficult to diagnose retrospectively or via outcome data alone. As observers are an instrument of data collection, developing effective and comprehensive observer training is critical to ensuring the reliability of the data collection and reproducibility of the research. However, methodological rigour for ensuring these data collection properties remains a key challenge in direct observation research in healthcare. Although prior literature has offered key considerations for observational research in healthcare, operationalising these recommendations may pose a challenge and unless guidance is also provided on observer training. In this article, we offer guidelines for training non-clinical observers to conduct direct observations including conducting a training needs analysis, incorporating practice observations and evaluating observers and inter-rater reliability. The operationalisation of these guidelines is described in the context of a 5-year multisite observational study investigating technology integration in the operating room. We also discuss novel tools developed during the course our project to support data collection and examine inter-rater reliability among observers in direct observation studies.

The introduction of surgical technology into existing operating rooms (ORs) can place novel demands on staff and infrastructure. Despite the substantial physical size of the devices in robotic-assisted surgery (RAS), the workspace implications are rarely considered. This study aimed to explore the impact of OR size on the environmental causes of surgical flow disruptions (FDs) occurring during RAS. Fifty-six RAS procedures were observed at two academic hospitals between July 2019 and January 2021 across general, urologic, and gynecologic surgical specialties. A multiple regression analysis demonstrated significant effects of room size in the pre-docking phase (t = 2.170, df = 54, β = 0.017, p = 0.035) where the rate of FDs increased as room size increased, and docking phase (t = −2.488, df = 54, β = −0.017, p = 0.016) where the rate of FDs increased as room size decreased. Significant effects of site (pre-docking phase: p = 0.000 and docking phase: p = 0.000) were also demonstrated. Findings from this study demonstrate hitherto unrecognized spatial challenges involved with introducing surgical robots into the operating domain. While new technology may provide benefits towards patient safety, it is important to consider the needs of the technology prior to integration.

Objective To evaluate the potential for a smartphone application to improve trauma care through shared and timely access to patient and contextual information. Background Disruptions along the trauma pathway that arise from communication, coordination, and handoffs problems can delay progress through initial care, imaging diagnosis, and surgery to intensive care unit (ICU) disposition. Implementing carefully designed and evaluated information distribution and communication technologies may afford opportunities to improve clinical performance. Methods This was a pilot evaluation “in the wild” using a before/after design, 3 month, and pre- post-intervention data collection. Use statistics, usability assessment, and direct observation of trauma care were used to evaluate the app. Ease of use and utility were assessed using the technology acceptance model (TAM) and system usability scale (SUS). Direct observation deployed measures of flow disruptions (defined as “deviations from the natural progression of an procedure”), teamwork scores (T-NOTECHS), and treatment times (total time in emergency department [ED]). Results The app was used in 367 (87%) traumas during the trial period. Usability was generally acceptable, with higher scores found by operating room (OR), ICU, and neuro and orthopedic users. Despite positive trends, no significant effects on flow disruptions, teamwork scores, or treatment times were observed. Conclusions Pilot trials of a clinician-centered smartphone app to improve teamwork and communication demonstrate potential value for the safety and efficiency of trauma care delivery as well as benefits and challenges of “in-the-wild” evaluation.

Summary Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

BACKGROUND: The introduction of a robot into the surgical suite changes the dynamics of the work-system, creating new opportunities for both success and failure. An extensive amount of research has identified a range of barriers to safety and efficiency in Robotic Assisted Surgery (RAS), such as communication breakdowns, coordination failures, equipment issues, and technological malfunctions. However, there exists very few solutions to these barriers. The purpose of this review was to identify the gap between identified RAS work-system barriers and interventions developed to address those barriers. METHODS: A search from three databases (PubMed, Web of Science, and Ovid Medline) was conducted for literature discussing system-level interventions for RAS that were published between January 1, 1985 to March 17, 2020. Articles describing interventions for systems-level issues that did not involve technical skills in RAS were eligible for inclusion. RESULTS: A total of 30 articles were included in the review. Only seven articles (23.33%) implemented and evaluated interventions, while the remaining 23 articles (76.67%) provided suggested interventions for issues in RAS. Major barriers identified included disruptions, ergonomic issues, safety and efficiency, communication, and non-technical skills. Common solutions involved team training, checklist development, and workspace redesign. CONCLUSION: The review identified a significant gap between issues and solutions in RAS. While it is important to continue identifying how the complexities of RAS affect operating room (OR) and team dynamics, future work will need to address existing issues with interventions that have been tested and evaluated. In particular, improving RAS-associated non-technical skills, task management, and technology management may lead to improved OR dynamics associated with greater efficiency, reduced costs, and better systems-level outcomes.

Simulations offer the benefits of a safer and more accessible learning environment, where learners can practice until the point of proficiency. While research into the effectiveness of simulations as learning tools has found tangible benefits, fewer studies have examined retention and differences between high and low fidelity simulations. This research sought to supplement the literature in this domain by investigating whether participants who learned to construct an electrical circuit using a 2D or 3D breadboard simulation could achieve comparable learning, transfer, and retention outcomes to those who learned using a physical breadboard. The influence of learner characteristics - cognitive ability and goal orientation - were also evaluated. This study had two parts: a cross-sectional portion that examined learning and transfer outcomes and a longitudinal portion that examined retention outcomes after a 2 and 4-week period. The cross-sectional analysis included 70 participants and the longitudinal analysis included 40 participants. The results found that the physical fidelity of the learning environment significantly impacted several transfer outcomes (construction and construction time) but not retention outcomes. Cognitive ability was a significant predictor of learning (gain score, circuit design score) and retention (posttest scores, construction time) outcomes. Learning goal orientation significantly predicted circuit construction over time and measurement occasion significantly predicted posttest scores and interacted with fidelity to predict circuit design score. The study demonstrated that simulated environments can lead to comparable, or better, proficiency than physical environments. These findings have implications for the design and implementation of simulated environments, specifically for courses delivered in an online setting.

This article describes a pilot trial of an internet-distributable online software package that provides course materials and built-in evaluation tools to train healthcare workers in high-risk infectious disease response. It includes (1) an online self-study component, (2) a "hands-on" simulation workshop, and (3) a data-driven performance assessment toolset to support debriefing and course reporting. This study describes a pilot trial of the software package using a course designed to provide education in Ebola response to prepare healthcare workers to safely function as a measurable, high-reliability team in an Ebola simulated environment. Eighteen adult volunteer healthcare workers, including 9 novices and 9 experienced participants, completed an online curriculum with pre- and posttest, 13 programmed simulation training scenarios with a companion assessment tool, and a confidence survey. Both groups increased their knowledge test scores after completing the online curriculum. Simulation scenario outcomes were similar between groups. The confidence survey revealed participants had a high degree of confidence after the course, with a median confidence level of 4.5 out of 5.0 (IQR = 0.5). This study demonstrated the feasibility of using the online software package for the creation and application of an Ebola response course. Future studies could advance knowledge gained from this pilot trial by assessing timely distribution and multi-site effectiveness with standard education.

The use of 2D and 3D simulated learning environments in education and training has increased significantly in the past decade. Simulated learning environments provide several advantages over physical learning environments including increased safety and accessibility. Simulated learning environments can also be utilized in an online setting, increasing the efficiency of delivery, access, and supporting greater personalization of the learning process. Despite a long history of use in workforce education, researchers have questioned whether simulations provide learners with the same quality of education as physical learning environments. This research investigated how learning to construct electrical circuits using a 2D simulation, a 3D simulation or a physical breadboard impacted learning outcomes. Additionally, this study examined the influence of learner characteristics, cognitive ability and goal orientation, on the relationship between the simulated learning environments and learning outcomes. The study utilized a pretest-posttest between subjects design and included 48 participants. Results suggest that learning to construct a circuit with physical components results in higher self-efficacy, faster construction times, and higher odds of correct construction than learning in a 2D or 3D simulation. Participants in the three conditions achieved comparable results in terms of cognitive outcomes; the differences identified were based on cognitive ability and goal orientation. There were no significant differences in outcomes achieved between participants in the 2D and 3D simulations. Implications for the design of simulated learning environments and potential impact for online technical curriculum are discussed. Relevance to industry This study supports the evaluation of using online educational technology to learn technical skills. This is relevant to workforce education, especially with a diverse and distributed workforce that requires technical training.

Handoffs occur frequently in healthcare systems, and miscommunications and critical omissions within handoffs have been linked to serious medical errors. Handoff quality is a priority of patient safety initiatives across several international organizations. The majority of previous research in handoffs have focused on postoperative handoffs; yet, there is a need to specifically investigate intraoperative handoffs, especially within individual professions or subspecialties. Each subspecialty within a surgical team may approach handoffs differently. The anesthesia team is especially unique as they take a team-based approach to patient care where multiple anesthesia providers may be involved in one surgical case. We describe an observational study of intraoperative and intraprofessional handoffs in anesthesia. Temporary and permanent handoffs were investigated as well as the contextual elements that influenced handoff procedures. In a sample of 35 video recorded surgeries, a total of 16 handoffs were identified for the maintenance phase of surgery. These handoffs ranged between 33 seconds and 7.42 minutes in duration. Our study revealed variability in intraoperative handoffs during the maintenance phase of anesthesia and emphasizes that intraoperative and intraprofessional handoffs warrant more in-depth examination in order to develop effective strategies or tools for high quality handoffs in anesthesia.

Quality and safety concerns in health care over the past 20 years precipitated the need to move beyond the traditional view of health care as an artisanal process toward a sociotechnical systems view of performance. The adoption of industrial approaches placed a greater emphasis on standardization of processes and outcomes, often treating humans as the “weak” part of the system rather than valuing their role in holding together complex, opaque, and unpredictable clinical systems. Although some health care tasks can be modeled linearly, others are much more complex. Efforts to reduce variation in clinical reasoning through evidence-based practices have proven problematic by failing to provide a means for context-specific adaptation or to account for the complex and adaptive nature of clinical work. We argue that the current, highly empirical approach to clinical decision making reflects clinical reasoning “as imagined,” whereas the application of the naturalistic decision-making (NDM) paradigm can help reveal clinical reasoning “as done.” This approach will have benefits for improving the conditions for diagnosis; the design of acute, time-pressured clinical work; the identification of deteriorating patients; the development of clinical decision support systems; and many more clinical tasks. Health care seems ready to accept NDM approaches.

This systematic review provides information on the methodologies, measurements and classification systems used in observational studies of flow disruptions in clinical environments. The PRISMA methodology was applied and authors searched two databases (PubMed and Web of Science) for studies meeting the following inclusion criteria: (a) were conducted in a healthcare setting, (b) explored systems-factors leading to deviations in care processes, (c) were prospective and observational, (d) classified observations, and (e) were original research studies published in peer-reviewed journals. Thirty studies were analyzed and a variety of methods were identified for observer training, data collection and observation classification. Although primarily applied in surgery, comparable research has been successfully conducted in other venues such as trauma care, and delivery rooms. The findings of this review were synthesized into a framework of considerations for conducting rigorous methodological studies aimed at understanding clinical systems.

Few studies that have evaluated the efficacy of learning in simulated environments have also examined differences in the processes that learners in the simulated environments employed to arrive at the outcomes being measured. In this video analysis study, the researchers sought to understand whether there were differences in the construction process used by participants who learned to construct circuits using a 2D simulation, a 3D simulation, or a physical breadboard and whether these differences subsequently impacted several learning outcomes. The researchers systematically reviewed 30 videos (10 videos per condition) of participants’ circuit construction to identify variations in their comprehension level and their construction procedures. The study found differences in the construction process, odds of successful construction, and construction time for participants in the three conditions that could be attributed to differences in fidelity. These findings provide valuable insights about how learning in simulated environments impact proficiency and learning and can help improve the design of simulated learning environments.

Achieving reliable instrument reprocessing requires finding the right balance among cost, productivity, and safety. However, there have been few attempts to comprehensively examine sterile processing department (SPD) work systems. We considered an SPD as an example of a socio-technical system - where people, tools, technologies, the work environment, and the organization mutually interact - and applied work systems analysis (WSA) to provide a framework for future intervention and improvement. The study was conducted at two SPD facilities at a 700-bed academic medical center servicing 56 onsite clinics, 31 operating rooms (ORs), and nine ambulatory centers. Process maps, task analyses, abstraction hierarchies, and variance matrices were developed through direct observations of reprocessing work and staff interviews and iteratively refined based on feedback from an expert group composed of eight staff from SPD, infection control, performance improvement, quality and safety, and perioperative services. Performance sampling conducted focused on specific challenges observed, interruptions during case cart preparation, and analysis of tray defect data from administrative databases. Across five main sterilization tasks (prepare load, perform double-checks, run sterilizers, place trays in cooling, and test the biological indicator), variance analysis identified 16 failures created by 21 performance shaping factors (PSFs), leading to nine different outcome variations. Case cart preparation involved three main tasks: storing trays, picking cases, and prioritizing trays. Variance analysis for case cart preparation identified 11 different failures, 16 different PSFs, and seven different outcomes. Approximately 1% of cases had a tray with a sterilization or case cart preparation defect and 13.5 interruptions per hour were noted during case cart preparation. While highly dependent upon the individual skills of the sterile processing technicians, making the sterilization process less complex and more visible, managing interruptions during case cart preparation, improving communication with the OR, and improving workspace and technology design could enhance performance in instrument reprocessing.

Achieving reliable instrument reprocessing requires finding the right balance among cost, productivity, and safety. However, there have been few attempts to comprehensively examine sterile processing department (SPD) work systems. We considered an SPD as an example of a socio-technical system - where people, tools, technologies, the work environment, and the organization mutually interact - and applied work systems analysis (WSA) to provide a framework for future intervention and improvement. The study was conducted at two SPD facilities at a 700-bed academic medical center servicing 56 onsite clinics, 31 operating rooms (ORs), and nine ambulatory centers. Process maps, task analyses, abstraction hierarchies, and variance matrices were developed through direct observations of reprocessing work and staff interviews and iteratively refined based on feedback from an expert group composed of eight staff from SPD, infection control, performance improvement, quality and safety, and perioperative services. Performance sampling conducted focused on specific challenges observed, interruptions during case cart preparation, and analysis of tray defect data from administrative databases. Across five main sterilization tasks (prepare load, perform double-checks, run sterilizers, place trays in cooling, and test the biological indicator), variance analysis identified 16 failures created by 21 performance shaping factors (PSFs), leading to nine different outcome variations. Case cart preparation involved three main tasks: storing trays, picking cases, and prioritizing trays. Variance analysis for case cart preparation identified 11 different failures, 16 different PSFs, and seven different outcomes. Approximately 1% of cases had a tray with a sterilization or case cart preparation defect and 13.5 interruptions per hour were noted during case cart preparation. While highly dependent upon the individual skills of the sterile processing technicians, making the sterilization process less complex and more visible, managing interruptions during case cart preparation, improving communication with the OR, and improving workspace and technology design could enhance performance in instrument reprocessing.

Background The integration of high technology into health care systems is intended to provide new treatment options and improve the quality, safety, and efficiency of care. Robotic-assisted surgery is an example of high technology integration in health care, which has become ubiquitous in many surgical disciplines. Objective This study aims to understand and measure current robotic-assisted surgery processes in a systematic, quantitative, and replicable manner to identify latent systemic threats and opportunities for improvement based on our observations and to implement and evaluate interventions. This 5-year study will follow a human factors engineering approach to improve the safety and efficiency of robotic-assisted surgery across 4 US hospitals. Methods The study uses a stepped wedge crossover design with 3 interventions, introduced in different sequences at each of the hospitals over four 8-month phases. Robotic-assisted surgery procedures will be observed in the following specialties: urogynecology, gynecology, urology, bariatrics, general, and colorectal. We will use the data collected from observations, surveys, and interviews to inform interventions focused on teamwork, task design, and workplace design. We intend to evaluate attitudes toward each intervention, safety culture, subjective workload for each case, effectiveness of each intervention (including through direct observation of a sample of surgeries in each observational phase), operating room duration, length of stay, and patient safety incident reports. Analytic methods will include statistical data analysis, point process analysis, and thematic content analysis. Results The study was funded in September 2018 and approved by the institutional review board of each institution in May and June of 2019 (CSMC and MDRH: Pro00056245; VCMC: STUDY 270; MUSC: Pro00088741). After refining the 3 interventions in phase 1, data collection for phase 2 (baseline data) began in November 2019 and was scheduled to continue through June 2020. However, data collection was suspended in March 2020 due to the COVID-19 pandemic. We collected a total of 65 observations across the 4 sites before the pandemic. Data collection for phase 2 was resumed in October 2020 at 2 of the 4 sites. Conclusions This will be the largest direct observational study of surgery ever conducted with data collected on 680 robotic surgery procedures at 4 different institutions. The proposed interventions will be evaluated using individual-level (workload and attitude), process-level (perioperative duration and flow disruption), and organizational-level (safety culture and complications) measures. An implementation science framework is also used to investigate the causes of success or failure of each intervention at each site and understand the potential spread of the interventions. International Registered Report Identifier (IRRID) DERR1-10.2196/25284

One anesthesia provider is often responsible for prescribing, formulating, dispensing, administering, and documenting medications in the operating room. Unlike other hospital units, there are few safety interventions. Systems engineering approaches can provide important insights into improving patient safety during medication delivery processes (Kaplan et al., 2013; Reid et al., 2005). This study observed anesthesia medication delivery during 20 anesthetic cases in the OR and interviewed 10 anesthesia providers in a large midatlantic academic hospital using a Systems Engineering Initiative for Patient Safety (SEIPS) framework to identify process risk in perioperative medication delivery (Holden et al., 2013). Anesthesia attendings, fellows, residents, and certified resident nurse anesthetists (CRNAs) were sampled based on who was in the OR during observations and who volunteered for interviews. Interviews were transcribed and coded through a consensus procedure. The medication delivery process was described using a SEIPS-based process map. Tasks were separated based on the anesthesia phase, though the tasks and phases are not linear; e.g: a provider may prepare for the next case during the maintenance phase.

A roboticist by the name of Rodney Brooks once said, “the benefits of having robots could vastly outweigh the problems.” While this may be true, it is important to assess these problems and understand how they may be mitigated. The use of robots is growing in many industries and can be found in areas such as manufacturing, healthcare, agriculture, food preparation and national defense. Within healthcare, robots are commonly used in surgery to perform procedures such as sacrocolpopexies, prostatectomies, hysterectomies, hernia repairs and nephrectomies. The benefits of robotic-assisted surgery (RAS) are similar to laparoscopy and include decreased blood loss, faster recovery time, and shorter lengths of stay at the hospital. Unlike purely laparoscopic surgery, the robot provides wrist dexterity, allowing for more complex surgeries to be performed in a minimally invasive fashion by surgeons who may not have expertise in laparoscopy. However, recent reports have heightened challenges facing RAS operating room (OR) teams. Effects of the OR layout, team communication, team coordination, disruptions to workflow, and equipment malfunctions were among the issues observed in a variety of RAS procedures. Issues such as disruptions to the workflow trigger delays and inefficiencies, which in turn could affect patient safety and quality of care. As part of a wider study to implement and evaluate multiple interventions associated with improving efficiency and safety of RAS, a literature search was conducted to investigate issues experienced by the OR team in RAS and the interventions developed and tested to resolve these issues. The literature search excluded studies concerned with laparoscopic and open surgery; proficiency training; and articles that were not written in English. Commentaries, editorials, and abstracts were further excluded. At the conclusion of the literature search, 17 articles involving the implementation or evaluation of interventions surrounding RAS were evaluated and categorized based on the issues that were addressed. Seven articles discussed disruptions to the OR team’s workflow; five articles discussed issues with patient safety, surgical complications, or risk assessment; three papers discussed issues with teamwork; and the remaining articles discussed issues with communication, efficiency, cognitive load, and surgical performance. Despite the number of articles that were found to discuss issues in RAS, only four of the 17 articles implemented interventions. The interventions primarily included the use of checklists and nontechnical skills training. The scarce number of articles focusing on interventions aimed at improving the safety, quality, and efficiency of RAS demonstrates the wide gap that exists between known problems and potential solutions. As the number of robotic-assisted procedures continue to grow, it is important to improve OR team efficiency and patient care. The current study is part of a five-year, four-site study investigating the nature of issues that exist in RAS. The larger study will also design and implement interventions based on RAS observations conducted by the researchers in an effort to ensure that the benefits of robotic surgery truly do outweigh the existing problems.

BackgroundFew studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes.ObjectiveIn this paper we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions.MethodsThe research was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23 000 units each month. Mixed methods, including 56 hours of observations of work as done, formal and informal interviews with relevant stakeholders and analysis of data collected about the system, were used to iteratively develop a process map, task analysis, abstraction hierarchy and a variance matrix.ResultsWe identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly, while decontamination problems were found in about 1% of surgical cases. Staff knowledge, production pressures, instrument design, tray composition and workstation design contributed to outcomes such as reduced throughput, tray defects, staff injuries, increased inventory and equipment costs, and patient injuries.ConclusionsEnsuring patients and technicians’ safety and efficient SPD operation requires improved design of instruments and the decontamination area, skilled staff, proper equipment maintenance and effective coordination of reprocessing tasks.

Technology, such as simulations and virtual reality (VR), can be used for training students and employees. Using these tools may have implications for skills development and retention, specifically related to individual differences and technology’s effectiveness as a learning tool. To explore this issue, a pilot study was used to evaluate how an individual’s performance on a task (i.e., the building an electrical circuit), differs depending on the physical fidelity of the learning environment. In addition, this study examined the effects of cognitive ability and goal orientation on task performance. Specifically this study investigated different methods for practicing the building of electrical circuits using a 2D breadboard simulation, a 3D virtual breadboard, and a physical breadboard. The preliminary results of this pilot study found that physical fidelity of learning environment was a significant predictor of construction time and circuit accuracy. Cognitive ability and learning goal orientation were significant predictors of gain scores and diagram accuracy.

Background: Highly infectious but rare diseases require rapid dissemination of safety critical skills to health-care workers (HCWs). Simulation is an effective method of education; however, it requires competent instructors. We evaluated the efficacy of an internet-delivered train-the-trainer course to prepare HCWs to care for patients with Ebola virus disease (EVD). Methods: Twenty-four individuals without prior EVD training were recruited and divided into two groups. Group A included nine trainees taught by three experienced trainers with previous EVD training. Group B included 15 trainees taught by five novice trainers without previous EVD training who completed the train-the-trainer course. We compared the efficacy of the train-the-trainer course by examining subject performance, measured by time to complete 13 tasks and the proportion of steps per task flagged for critical errors and risky and positive actions. Trainees’ confidence in their ability to safely care for EVD patients was compared with a self-reported survey after training. Results: Overall trainees’ confidence in ability to safely care for EVD patients did not differ by group. Participants trained by the novice trainers were statistically significantly faster at waste bagging (P = 0.002), lab specimen bagging (P = 0.004), spill clean-up (P = 0.01), and the body bagging (P = 0.008) scenarios compared to those trained by experienced trainers. There were no significant differences in the completion time in the remaining nine training tasks. Participants trained by novice and experienced trainers did not differ significantly with regard to the proportion of steps in a task flagged for critical errors, risky actions, or positive actions with the exception of the task “Man Down in Gown” (12.5% of steps graded by experienced trainers compared to 0 graded by novice trainers, P = 0.007). Discussion: The online train-the-trainer EVD course is effective at teaching novices to train HCWs in protective measures and can be accomplished swiftly.