Search

Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX).We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL.Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect.CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.

Objective Primary care efficiency and quality are essential for the nation’s health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns. Methods This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit’s progression, and the presence of an electronic health record (EHR) at the clinic. Results PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit. Discussion PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a “dance” between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice. Conclusions Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP’s mental and physical work, resulting in effective, safe, and efficient primary care.

Health information technology (IT) is a promising way to achieve safer medication management in the delivery of healthcare. However, human factors/ergonomics dictates that in order to make the complex, cognitive work of healthcare delivery safer, health IT must properly support human cognition. This means, for example, that new health IT must reduce, not increase, workload during safety-critical tasks. The present study was the first to quantitatively assess the short- and long-term impact of bar coded medication administration (BCMA) IT on nurses' mental workload as well as on perceived medication safety. One-hundred seventy registered nurses across 3 dissimilar clinical units at an academic, freestanding pediatric hospital in the Midwest US participated in surveys administered before, 3 months after, and 12 months after the hospital implemented BCMA. Nurses rated their external mental workload (interruptions, divided attention, being rushed) and internal mental workload (concentration, mental effort) during medication administration tasks as well as the likelihood of each of three medication safety events: medication administration errors, medication errors on the clinical unit, and clinical unit-level adverse drug events. Clinical unit differences were assessed. Findings generally confirmed the hypothesis that external but not internal mental workload was associated with the perceived likelihood of a medication safety event. Comparisons of mental workload from pre- to post-BCMA revealed statistically significant changes in the critical care unit only. Medication safety appeared to improve over the long term in the hematology/oncology unit only. In the critical care and medical/surgical units, medication safety exhibited short-term improvements that were eliminated over time. Changes in mental workload and medication safety, two classically microergonomic constructs, were deeply embedded in macroergonomic phenomena. These included the fit between the BCMA system and the nature of nursing work, the process of BCMA implementation, and BCMA interactions with concurrent changes occurring in the hospital. Findings raise questions about achieving sustainable performance improvement with health IT as well as the balance between micro- and macroergonomic approaches to studying technology change. Relevance to industry Designers must consider how technology changes cognitive work, including mental workload. Hospitals and other implementers of technology must ensure that new technology fits its users, their tasks, and the context of use, which may entail tailoring implementation, for example, to specific clinical units. Evaluators must look over time to assess both changes in cognitive work and implementation issues. Healthcare practitioners must also recognize that new technology means a complex transformation to an already complex sociotechnical system, which calls for a macroergonomic approach to design and analysis.

In this paper we elaborate and articulate the need for what has been termed ‘mesoergonomics’. In particular, we argue that the concept has the potential to bridge the gap between, and integrate, established work within the domains of micro- and macroergonomics. Mesoergonomics is defined as an open systems approach to human factors and ergonomics (HFE) theory and research whereby the relationship between variables in at least two different system levels or echelons are studied, and where the dependent variables are human factors and ergonomic constructs. We present a framework which can be used to structure a set of questions for future work and prompt further empirical and conceptual inquiry. The framework consists of four steps: (1) establishing the purpose of the mesoergonomic investigation; (2) selecting human factors and ergonomics variables; (3) selecting a specific type of mesoergonomic investigation; and, (4) establishing relationships between system levels. In addition, we describe two case studies which illustrate the workings of the framework and the value of adopting a mesoergonomic perspective within HFE. The paper concludes with a set of issues which could form part of a future agenda for research within systems ergonomics.

Purpose When barcode medication administration (BCMA) is implemented nurses are required to integrate not only a new set of procedures or artifacts into everyday work, but also an orientation to medication safety itself that is sometimes at odds with their own. This paper describes how the nurses' orientation (the Practice Frame) can collide with the orientation that is represented by the technology and its implementation (the System Frame), resulting in adaptations at the individual and organization levels. Methods The paper draws on two qualitative research studies that examined the implementation of BCMA in inpatient settings using observation and ethnographic fieldwork, content analysis of email communications, and interviews with healthcare professionals. Results Two frames of reference are described: the System Frame and the Practice Frame. We found collisions of these frames that prompted adaptations at the individual and organization levels. The System Frame was less integrated and flexible than the Practice Frame, less able to account for all of the dimensions of everyday patient care to which medication administration is tied. Conclusion Collisions in frames during implementation of new technology result in adaptations at the individual and organization level that can have a variety of effects. We found adaptations to be a means of evolving both the work routines and the technology. Understanding the frames of clinical workers when new technology is being designed and implemented can inform changes to technology or organizational structure and policy that can preclude unproductive or unsafe adaptations.

Background Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement. Methods The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities. Results The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value. Conclusions The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety.

Objective To identify predictors of nurses' acceptance of bar coded medication administration (BCMA). Design Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA. Methods Surveys assessed seven BCMA-related perceptions: ease of use; usefulness for the job; social influence from non-specific others to use BCMA; training; technical support; usefulness for patient care; and social influence from patients/families. An all possible subset regression procedure with five goodness-of-fit indicators was used to identify which set of perceptions best predicted BCMA acceptance (intention to use, satisfaction). Results Nurses reported a moderate perceived ease of use and low perceived usefulness of BCMA. Nurses perceived moderate-or-higher social influence to use BCMA and had moderately positive perceptions of BCMA-related training and technical support. Behavioral intention to use BCMA was high, but satisfaction was low. Behavioral intention to use was best predicted by perceived ease of use, perceived social influence from non-specific others, and perceived usefulness for patient care (56% of variance explained). Satisfaction was best predicted by perceived ease of use, perceived usefulness for patient care, and perceived social influence from patients/families (76% of variance explained). Discussion Variation in and low scores on ease of use and usefulness are concerning, especially as these variables often correlate with acceptance, as found in this study. Predicting acceptance benefited from using a broad set of perceptions and adapting variables to the healthcare context. Conclusion Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.

Background The safety benefits of bar-coded medication-dispensing and administration (BCMA) technology depend on its intended users favorably perceiving, accepting, and ultimately using the technology. Objectives (1) To describe pharmacy workers’ perceptions and acceptance of a recently implemented BCMA system and (2) to model the relationship between perceptions and acceptance of BCMA. Methods Pharmacists and pharmacy technicians at a Midwest U.S. pediatric hospital were surveyed following the hospital’s implementation of a BCMA system. Twenty-nine pharmacists' and 10 technicians’ self-reported perceptions and acceptance of the BCMA system were analyzed, supplemented by qualitative observational and free-response survey data. Perception-acceptance associations were analyzed using structural models. Results The BCMA system’s perceived ease of use was rated low by pharmacists and moderate by pharmacy technicians. Both pharmacists and technicians perceived that the BCMA system was not useful for improving either personal job performance or patient care. Pharmacy workers perceived that individuals important to them encouraged BMCA use. Pharmacy workers generally intended to use BCMA but reported low satisfaction with the system. Perceptions explained 72% of the variance in intention to use BCMA and 79% of variance in satisfaction with BCMA. Conclusions To promote their acceptance and use, BCMA and other technologies must be better designed and integrated into the clinical work system. Key steps to achieving better design and integration include measuring clinicians’ acceptance and elucidating perceptions and other factors that shape acceptance.

The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices.To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices.We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach.All practice members and selected patients in seven community-based primary care practices in the Northeastern US.The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care.The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

Content Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process. Objective To assess the extent of violations in the medication administration process among nurses. Design, setting and participants Participants were 199 nurses from two US urban, academic, tertiary care, free-standing paediatric hospitals who worked in a paediatric intensive care unit (PICU), a haematology-oncology-transplant (HOT) unit or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process. Main outcome measure Self-reported violations of three medication administration protocols were made using a seven-point 0–6 scale from ‘not at all’ to ‘a great deal’. Results Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses and then Med/Surg unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant three-way interaction among violation situation, step in the process, and unit. Conclusions Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital unit, step in the process, and violation situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol to accomplish job tasks.

Background Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit. Methods A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings. Results The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student. Conclusions The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.

Background: The wide-reaching, complex, understudied primary care environment presents hazards to patient safety. Elderly patients visit physician offices more often, with more problems, while taking more medications – increasing the complexity of the visit and the frequency of the hazards. Objective: Identify hazards in the primary care of elderly patients from the patient’s perspective. Methods: Fourteen elderly patients in three focus groups with questions developed from 70 hours of direct observation. Hazards were coded from participant responses and ‘what-if’ analyses to capture both explicit and implicit hazards. Results: Thematic hazard analysis resulted in eight emergent, overlapping hazard themes: 1) fragmentation of care; 2) problems with information transfer between healthcare professionals; 3) problems with patient communication and feedback; 4) problems with paper and electronic health records; 5) medication management and expense; 6) physical and memory limitations; 7) reliance on others; an...

Given the rising costs of health care, the current focus on improving patient safety, and the goals of reducing barriers to efficient healthcare access, there is a strong and rapid push towards the implementation of health information systems in a variety of health care contexts. This panel brings together individuals with experiences spanning human factors and system safety research, medical informatics, and clinical practice to provide a set of diverse but complementary viewpoints on what it will take to successfully, safely, and meaningfully design and implement health information systems.

BACKGROUND: Traumatic and musculoskeletal injury rates have been high in dairy farming compared to other industries. Previous work has shown that social marketing efforts can persuade farm managers to adopt practices that reduce injury hazards compared to traditional practices if the new practices maintain profits. METHODS: The intervention disseminated information to 4,300 Northeast Wisconsin dairy farm managers about three safer and more profitable production practices (barn lights, silage bags, and calf feed mixing sites) using information channels that these managers were known to rely on. We evaluated rolling, independent, community-based samples, at baseline and then again after each of four intervention years. We also evaluated samples from Maryland's 1,200 dairy farms after the second through the fourth year of the intervention. Maryland dairy managers read many of the same nationally distributed print mass media that we used in the intervention and so were a "partially exposed" comparison group. RESULTS: The intervention to disseminate information about the innovations was successful. In comparisons before and after the intervention, Wisconsin managers reported getting more information about calf sites from public events and equipment dealers, about silage bags from other farmers and equipment dealers, and about barn lights from public events, other farmers, equipment dealers, consultants, and electrical suppliers. Wisconsin managers also reported getting more information than Maryland managers from public events for barn lights and silage bags. During years three and four, the intervention managed to sustain, but not improve, earlier increases in adoption and awareness from the first 2 years. After adjusting for farm manager and operation variables, intervention years was associated with increased Wisconsin manager adoption of two of three practices in comparisons between the baseline and the fourth intervention year: barn lights (odds ratio = 5.58, 95% confidence interval = 3.39-9.17) and silage bags (OR = 2.94, CI = 1.84-4.70). There were similar results for awareness of barn lights and the calf feeding sites. Compared to Maryland managers, Wisconsin managers reported greater awareness of barn lights. CONCLUSIONS: Disseminating information to managers through information channels that they usually consulted was associated with increased reports of getting information and with greater adoption and awareness of safer, profit-enhancing work practices in a high hazard industry. Am. J. Ind. Med. © 2010 Wiley-Liss, Inc. Language: en

Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.

Human expertise is limited by both cognitive workload and the boundaries of attention. With the spread and integration of healthcare informatics, cognitive decision support (CDS) technologies have been suggested as a means for improving the effectiveness and efficiency of healthcare. The current panel brings together leading human factors and medical experts in the fields of decision-making, design, and human-system interaction to provide their insight and perspective on the following question: What contributions can human factors science bring to bear on (1) the design, (2) integration, and (3) training necessary for effective CDS implementation?

Preventable patient harm due to errors in medication ordering, transcribing, dispensing and administration is a significant problem as discussed in the Institute of Medicine's 2007 report “Preventing Medication Errors”. Additionally, the report states that there are “enormous gaps in the knowledge base with regard to medication errors” and that the current methods available to solve this problem are inadequate (IOM, 2007, p2). Consequently, human factors research can contribute to the solution for this national problem by addressing the complexity in current medication systems and by designing user-centered solutions that support the real complex cognitive work of the clinicians. Panelists in this session, who have been funded by the federal government, private industry, and fellowships, will briefly share their human factors research on medication systems and then discuss how human factors researchers and practitioners can contribute to medication safety goals.

Conventional wisdom suggests that the "human factor" in critical care environments is reason for inadequate medication and patient safety. "Human factors" (or human factors engineering) is also a scientific discipline and practice of improving human performance. Using decades of human factors research, this paper evaluates a range of common beliefs about patient safety through a human factors lens. This evaluation demonstrates that human factors provides a framework for understanding safety failures in critical care settings, offers insights into how to improve medication and patient safety, and reminds us that the "human factor" in critical care units is what allows these time-pressured, information-intense, mentally challenging, interruption-laden, and life-or-death environments to function so safely so much of the time.

“The reality of the growing dissatisfaction with the practice of medicine has reached a crisis level”(Weinstein and Wolfe 2007). This belief has led to the growing number of studies of physician job satisfaction (Breslau, Novack, and Wolf 1978; Pasternak, Tuttle, and Smith 1986; Schulz and Schulz 1988; Buciuniene, Blazeviciene, and Bliudziute 2005; Scott et al. 2006; Van Ham et al. 2006; Whalley et al. 2006; Keeton et al. 2007;). Job satisfaction studies are important because they have identified outcomes linked to satisfaction, such as turnover (Beasley et al. 2004; Misra-Hebert, Kay, and Stoller 2004; Landon et al. 2006; Joseph et al. 2007; Wright and Bonett 2007;), cutting back hours (Landon et al. 2006), mental health (Williams et al. 2002), quality of care (Grembowski et al. 2005), and burnout (Linzer et al. 2001). Satisfied physicians also appear to engender greater satisfaction, trust, and confidence in their patients (Grembowski et al. 2005). Satisfaction studies are also important because they have identified job and organizational predictors of satisfaction (Gaertner 1999; Freeborn 2001; Duffy and Richard 2006; Van Ham et al. 2006;) that can be changed to improve satisfaction, and they decrease the likelihood of subsequent bad outcomes such as burnout or turnover. While physician satisfaction continues to receive attention, physician commitment has received far less (Lakin 1998; Burns et al. 2001; Freeborn 2001;). Outside of health care, commitment and satisfaction are considered among the two most important employee attitudes because both lead to a variety of important behaviors such a performance, turnover, absenteeism, and helping behaviors (Currivan 1999; Meyer and Herscovitch 2001; Wagner 2007; Solinger, van Olffen, and Roe 2008;). But for some reason, commitment has been largely ignored in studies of physicians. Commitment has been defined in many ways, but a common theme is that commitment to something can be thought of as the force that binds a person to something, where the “something” is typically a behavior (e.g., “I am committed to providing better care”) or an entity (e.g., “I am committed to my practice”) (Meyer and Herscovitch 2001). Commitment has cognitive, emotional, and behavioral components (Solinger, van Olffen, and Roe 2008). Low commitment can lead to behaviors such as turnover, but high commitment can lead to helping behaviors directed to patients or colleagues (Solinger, van Olffen, and Roe 2008), making the study of physician commitment an important gap to fill. Another important gap in the literature on physician attitudes, in addition to the omission of commitment, is that studies have not examined satisfaction and commitment directed to the entities that physicians most associate themselves with: one's practice, one's workgroup (people with whom you take call), and one's employer, which we refer to as the physician's health care organization (HCO) or parent organization.1 Instead, existing research has typically only focused on the latter (Schulz, Girard, and Scheckler 1992; Burdi and Baker 1997; LePore and Tooker 2000; Linzer et al. 2000; Sturm 2001; Beasley et al. 2004, 2005). Results show that HMO employed and non-HMO physician satisfaction varies widely, as do the predictors of satisfaction. But these studies have not compared measures of satisfaction (or commitment) with entities that physicians affiliate. This is an important omission for at least two reasons: (a) satisfaction with or commitment toward these different entities may differentially predict outcomes such as turnover and job performance and (b) different variables may predict each type of satisfaction and commitment. If (a) and (b) are true, then current efforts to improve physician satisfaction and/or commitment may need to be redirected. This study is an attempt to fill that gap. The purpose of this study was to compare satisfaction and commitment scores among family physicians toward their practice, workgroup, and HCO and to determine what work factors predict the different types of satisfaction and commitment. The sample consisted of family medicine physicians employed by large multispecialty group practices, a group for whom this may be especially important in light of the low numbers of medical students intending to pursue a career in primary care (Hauer et al. 2008).

Background We conducted a 3 year intervention to increase awareness and adoption of eight more profitable nursery crop production practices that reduced certain traumatic and musculoskeletal injury hazards. Methods We disseminated information to nursery managers across seven states using information channels they were known to rely on (e.g. trade publications, public events, university Extension, other managers). We evaluated rolling, independent, probability samples (n = 1200) with mail questionnaires before the intervention and after each of 3 intervention years. We also evaluated samples (n = 250) from a comparison group of New Zealand nursery managers. Results The intervention was associated with increased awareness of four of the eight practices among US managers after year 3 compared to their baseline: zippers (20 vs. 32%, p ≤ 0.000), stools (11 vs. 22%, p ≤ 0.001), pruners (29 vs. 40%, p ≤ 0.014), and tarps (24 vs. 33%, p ≤ 0.009). There were no changes in adoption. New Zealand manager awareness was increased for hoes after year 2 compared to their baseline (35 vs. 52%, p ≤ 0.010). Conclusions A modest, regionwide information dissemination intervention was associated with increased awareness, but not adoption.

The proposed Macroergonomics and Patient Safety panel will address the particular challenges of technology in critical care and emergency medicine and patient safety. Critical care technology remains a driving force in American health care facilities, yet little human factors and systems engineering information is available to improve the design and implementation of these technologies. Given the complexity of the clinical technology and the intricacy of modern critical and emergent medical care, human factors (HF) and macroergonomic analysis (MA) are especially important in the design, implementation, and use of the various technologies. HF and MA should be used to better understand the challenge of developing multi-perspective evaluations for this technology. The panel of experts' presentations and the discussion to follow will address current problems and patient safety and integration of critical technologies.

Little recent research is available about where specific types of farm managers search for information about better production practices. The objective of this study was to investigate what information sources managers used and how they rated the usefulness of each source. The authors administered mail questionnaires to probability samples from sampling frames they developed for four groups: dairy and fresh market vegetable producers from Wisconsin and berry and nursery producers from a multistate region. Questionnaire items asked operation managers to check off, from a list of information sources, those that they used in the last year to learn about new equipment or procedures to improve their operations and then to rate the usefulness of each source. In the last year, nursery, dairy, and berry managers most often used information from print media (63% to 84%), followed by other farmers (50% to 80%). Fresh market vegetable growers used conferences (60%) most often, followed by print media (41%). The information source rated most useful was "other farmers" for the nursery, dairy, and fresh market vegetable managers. Nursery and fresh market vegetable managers rated conferences as second most useful, whereas dairy managers rated print media second. Berry managers were not asked about usefulness. Farm manager information behavior exhibits some common features but is also specific to their operation type. Research and outreach efforts intending to communicate information to farm managers may be able to be more efficient at reaching and persuading their intended audience if they first investigate manager information behavior.

The purpose of this study was to test the hypothesis that nurses' beliefs about the technology they use in practice would affect their perception of individual and unit quality of care. A survey was administered to 347 pediatric nurses (response rate = 57.3%) from two academic freestanding pediatric hospitals in the United States. Two separate equations were constructed; one tested whether technology beliefs affected perceived individual quality of care, and the other tested whether technology beliefs affected perceived quality of care provided by the nursing unit. Nurse confidence in their ability to use computer technology and their beliefs that the technologies fit task requirements were significant predictors of nurse beliefs that they and their unit were able to provide quality care to their patients.

Little research is available about the specifics of child or adolescent work on dairy farm operations. The objective of this study was to investigate work performed by children and adolescents on these operations. The authors administered mail questionnaires to a community-based, age- and operation size-stratified sample of individuals aged 6 to 18 (n = 240) who worked on dairy operations in Wisconsin. Data were collected in 1999. The 197 children and adolescents reported averaging 567 hours of dairy farm work in the last year (10.9 hours/week) and completed over 1/3 of all calf feeding, 1/5 of the milking, 1/5 of cow feeding, and 1/10 of tractor operation hours on their farm during the weeks they worked. Some of these young workers reported accomplishing duties also judged by some experts as hazardous work, including nearly half of the 9- to 11-year-olds driving tractors. Six nonfatal injuries were reported that required stopping work (14.6 per 100 full time equivalents per year), including those that required medical attention. Musculoskeletal discomfort and disability reports were unremarkable compared to existing studies of general and working populations. Wisconsin dairy farm youth appeared to be working no more hours per week than their peers in other studies of agricultural populations. Adolescents and some children largely performed the same range of tasks and often the same scope of work as adults, including some performing hazardous work. There is a need for further investigations with larger samples of dairy youth to confirm these findings. The exposures of very young workers to hazardous tractor driving and tower silo tasks suggest that there is an urgent need for improved and validated interventions to reduce these exposures.

Primary objective: Much research and practice related to the design and implementation of information technology in health care has been atheoretical. It is argued that using extant theory to develop testable models of health information technology (HIT) benefits both research and practice. Methods and procedures: several theories of motivation, decision making, and technology acceptance are reviewed and associated theory-based principles of HIT usage behaviour are produced. Main outcomes and results: the case of medical error reporting technology is used to support the validity of the proposed HIT usage behaviour principles. Further, combining these principles produces a testable, theoretical multilevel model of HIT usage behaviour. The model provides an alternative to atheoretical research and practice related to HIT. Conclusions: developing, testing, and revising models of HIT like the one presented here is suggested to be beneficial to researchers and practitioners alike.

Sicker patients with greater care needs are being discharged to their homes to assume responsibility for their own care with fewer nurses available to aid them. This situation brings with it a host of human factors and ergonomic (HFE) concerns, both for the home care nurse and the home care patient, which can affect quality of care and patient safety. Many of these concerns are related to the critical home care tasks of information access, communication, and patient self-management. Currently, a variety of consumer health information technologies (CHITs) are being promoted as possible solutions to those problems, but those same technologies bring with them a new set of HFE concerns. This article reviews the HFE considerations for information access, communication, and patient self-management, discusses how CHIT can potentially mitigate current problems, and explains how the design and implementation of CHIT itself requires careful HFE attention.

New healthcare technologies, such as bar-coded medication administration (BCMA), are implemented into rich, multiple-level work system, and jointly shape work processes. We provide theoretical and methodological rationale for studying these processes as a way to understand the impact of technologies in healthcare. Results are reported from a study conducted before and after implementation of BCMA in a pediatric hospital, in which the outcome of interest was satisfaction with the medication administration process. As predicted, two beliefs about the medication process, perceived ease of use and perceived usefulness, predicted satisfaction with the process before and after BCMA.

With the proliferation of macroergonomic field research, it is time to carefully examine how such research should be managed and implemented. We argue that the importance of attending to high-quality implementation of field research is equal to that of methodological rigor. One way to systematically manage the implementation process is to adopt a change management framework, wherein the research project is conceptualized as an instance of organization-level change. Consequently, principles for successful organization-level change from the literature on change management can be used to guide successful field research implementation. This paper briefly reviews that literature, deriving 30 principles of successful change management, covering topics such as political awareness, assembling the change team, generating buy-in, and management support. For each principle, corresponding suggestions for macroergonomic field research practice are presented. We urge other researchers to further develop and adopt frameworks that guide the implementation of field research.

The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors--the least likely medication error to be intercepted--these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.

A well accepted human factors concept is that poorly designed work systems can produce workload levels that pose a threat to safety and performance. The purpose of this study was to assess a systems model of workload and safety developed for nursing/healthcare. Using survey data from six nursing units in two pediatric hospitals, the study measured the relationship between self-reported workload at the unit, job, and task levels on the one hand and job dissatisfaction, burnout, and medication error likelihood on the other. Multiple linear and logistic regression revealed that staffing adequacy and medication administration workload strongly predicted the above patient and employee safety outcomes. Design priorities and strategies for future research are discussed, including the need for multiple-level approaches.

Violations present a path to medical injury that has, thus far, been largely unexplored. This paper focuses on violations of three medication administration protocols and tests the hypothesis that if current processes for completing these tasks are neither easy nor useful, or if there is dissatisfaction with the tasks, then violations will be more likely. Survey data were collected from 199 nurses in the pediatric intensive care units, hematology-oncology-transplant units, and medical-surgical units at two pediatric hospitals. The results of the logistic regressions did not support the hypothesis, though several significant predictors of violations were found. The predictors of violations, possible reasons the hypotheses were not supported, and considerations for measuring violations are discussed.

This study investigated the relationship between pneumatic nutrunner handle reactions, workstation characteristics, and prevalence of upper limb injuries in an automobile assembly plant. Tool properties (geometry, inertial properties, and motor characteristics), fastener properties, orientation relative to the fastener, and the position of the tool operator (horizontal and vertical distances) were measured for 69 workstations using 15 different pneumatic nutrunners. Handle reaction response was predicted using a deterministic mechanical model of the human operator and tool that was previously developed in our laboratory, specific to the measured tool, workstation, and job factors. Handle force was a function of target torque, tool geometry and inertial properties, motor speed, work orientation, and joint hardness. The study found that tool target torque was not well correlated with predicted handle reaction force (r=0.495) or displacement (r=0.285). The individual tool, tool shape, and threaded fastener joint hardness all affected predicted forces and displacements (p0.05). The average peak handle force and displacement for right-angle tools were twice as great as pistol grip tools. Soft-threaded fastener joints had the greatest average handle forces and displacements. Upper limb injury cases were identified using plant OSHA 200 log and personnel records. Predicted handle forces for jobs where injuries were reported were significantly greater than those jobs free of injuries (p0.05), whereas target torque and predicted handle displacement did not show statistically significant differences. The study concluded that quantification of handle reaction force, rather than target torque alone, is necessary for identifying stressful power hand tool operations and for controlling exposure to forces in manufacturing jobs involving power nutrunners. Therefore, a combination of tool, work station, and task requirements should be considered.

Medication errors are an important problem for the UK National Health Service (NHS). The aim of this study was to implement a novel quantitative modelling method to predict rates of preventable adverse drug events (ADEs) and identify interventions with the greatest potential for reducing the burden of medication errors in secondary care. A generic model structure was developed to describe the medication process in secondary care. The model followed pathways from error points through to the outcomes of undetected errors. The model was populated using quantitative estimates and calibration methods to describe the incidence and impacts of medication errors. The effectiveness of potential interventions was estimated by describing the impact of the interventions at different stages of the medication process. The model predicts the range of preventable adverse drug events that occur annually in a 400-bed hospital in the UK to be between 200 and 700. Of the interventions evaluated, computerised physician order entry systems and increased numbers of ward pharmacists are predicted to have the greatest impact on the number of preventable ADEs. The analysis provides a relative analysis of the interventions, and indicates priorities for research allocation decisions. The model highlights the complexity of the relationship between medication errors and adverse events, and the extreme attention to detail required in the development of interventions, and in their evaluation.

Objective: To review the literature on medical error reporting systems, identify gaps in the literature, and present an integrative cross-level systems model of reporting to address the gaps and to serve as a framework for understanding and guiding reporting system design and research. Background: Medical errors are thought to be a leading cause of death among adults in the United States. However, no review exists summarizing what is known about the barriers and facilitators for successful reporting systems, and no integrated model exists to guide further research into and development of medical error reporting systems. Method: Relevant literature was identified using online databases; references in relevant articles were searched for additional relevant articles. Results: The literature review identified components of medical error reporting systems, error reporting system design choices, barriers and incentives for reporting, and suggestions for successful reporting system design. Little theory was found to guide the published research. An integrative cross-level model of medical error reporting system design was developed and is proposed as a framework for understanding the medical error reporting literature, addressing existing limitations, and guiding future design and research. Conclusion: The medical error reporting research provides some guidance for designing and implementing successful reporting systems. The proposed cross-level systems model provides a way to understand this existing research. However, additional research is needed on reporting and related safety actions. The proposed model provides a framework for such future research. Application: This work can be used to guide the design, implementation, and study of medical error reporting systems.

Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper we describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.

The purpose of this paper is to present partial results of a model examining the impact of psychosocial work factors on nurses' perceptions of the quality of patient care they are able to provide. Psychosocial work factor variables characterizing the work environment were selected as predictors in the model. The independent variables were job demands, role conflict, task control, resource control, social support, and supervisory support. The dependent variable was a developed measure of perceived quality of care, with items assessing the technical and interpersonal aspects of providing quality care. Using a cross-sectional survey design, data was collected from 120 at a pediatric academic hospital. Results indicate that social support provides a key contribution to nurses' perceptions of quality of care.

The paper uses a new measure of protocol violations to explore the extent of violations in the medication administration process. 203 nurses in three units of a free-standing pediatric hospital were provided with a survey assessing violations in the medication administration process; 120 nurses responded for a response rate of 59%. Violation data were collected for three stages of the medication administration process: matching medications to the medication administration record, checking patient identification, and documenting administration. The percentage of nurses who reported violating protocol in the medication administration process ranged from 8.4% to 30.2% in routine situations, and from 32.2% to 53.0% in emergency situations. Violations in the medication administration process may lead to medication errors. To improve medication safety, efforts should be taken to discover the system deficiencies that produce such frequent violations. System redesign should then address these deficiencies.

The diagnosis of illness is important for quality patient care and patient safety and is greatly aided by diagnostic testing. For diagnostic tests, such as pathology and radiology, to positively impact patient care, the tests must be processed and the physician and patient must be notified of the results in a timely fashion. There are many steps in the diagnostic testing process, from ordering to result dissemination, where the process can break down and therefore delay patient care and reduce patient safety. This study was carried out to examine the diagnostic testing process (i.e. from ordering to result notification) and used a macro-ergonomic work system analysis to uncover system design flaws that contributed to delayed physician and patient notification of results. The study was carried out in a large urban outpatient health-care facility made up of 30 outpatient clinics. Results indicated a number of variances that contributed to delays, the majority of which occurred across the boundaries of different systems and were related to poor or absent feedback structures. Recommendations for improvements are discussed.

Objective: The study examined the differences between physicians and clinical assistants in their preferences for a statewide medical error reporting system. Background: Medical error reporting systems have been proposed as a means for studying the causes of medical error. Knowledge of user similarities and differences is needed for the development of design guidelines for medical error reporting systems. Method: Separate focus groups composed of 8 physicians and 6 clinical assistants (physician clinical support staff) were conducted. One-hour focus group meetings were conducted via toll-free teleconference lines one to two times per month for 9 months. All conversations were audiotaped and transcribed for analysis. An inductive content analysis was conducted. Results: Eighty-six major and minor themes emerged. Differences between physicians and clinical assistants included rules and regulations governing the use of the system, the medium of reporting, and aspects of the organization that may affect reporting levels. Conclusions: Although physicians and clinical assistants shared similar preferences and beliefs surrounding error reporting, there were differences that need to be considered if medical error reporting systems are to be effective. Application: To successfully deploy a medical error reporting system, the system itself must be designed for the potential users. This study uncovered previously underappreciated issues that should be incorporated into the design and implementation process. Actual or potential applications of this research include the improvement of the design and implementation of medical error reporting systems to account for the needs of different types of users.

There are a growing number of theories and models that describe how work-related musculoskeletal disorders (WMSDs) are caused. Nine of these theories and models are described, compared and contrasted. The models are then integrated to form a composite model that incorporates the various paths and mechanisms that have been proposed. This composite model illustrates the complexity of WMSD aetiology by describing 35 proposed pathways between the 12 major constructs that have been proposed in previous models. This complexity helps to explain difficulties encountered in interventions to control WMSDs. Several implications for ergonomic intervention research that are based on the integrated model are considered, including suggestions for measurement, treatment and analysis. Specific suggestions for measuring multiple outcomes, measuring and analysing possible confounders and selecting appropriate controls for known risk factors are discussed.

PURPOSE Family physicians in Wisconsin who are mainly employed by large health care organizations have voiced concerns regarding the quality of their work lives. We explored the quality of work life and its relationship to employment by health care organizations. METHODS We conducted a cross-sectional survey of the 1,482 active members of the Wisconsin Academy of Family Physicians in 2000. RESULTS A 47% overall response rate was obtained, and 584 respondents could be identifi ed as independent or employed by a health care organization. There were no differences in age or sex between the 2 groups. The independent physi- cians worked longer hours, were in smaller work groups, and had been in practice longer and in their current practice longer than the employed physicians. Inde- pendent physicians reported better working relationships, more satisfaction with family time, more infl uence over management decisions, better satisfaction with being a physician, better perceived quality of the care they provided, greater abil- ity to achieve professional goals, and lesser intention to leave the practice. CONCLUSIONS Independent physicians have signifi cantly more positive ratings of several aspects of the quality of their work life compared with physicians employed by health care organizations. Health care organizations need to address these issues if they are to have a satisfi ed and stable workforce.

The purposes of this study were to determine if users of electronic medical records (EMRs) perceived their medical records to be of higher quality than users of paper records and to examine the relationship between EMR use and perceptions of working conditions, quality of worklife and quality of care among family physicians. To do so, a cross-sectional survey of family physicians (n = 1482) was conducted. Survey items included measurement of use of an EMR, perceptions of medical records, working conditions, job satisfaction, and quality of care. One hundred and forty-three physicians (23%) reported using EMRs. Physicians who used EMRs were significantly more satisfied with the quality of their medical records. EMR use was not related to other outcomes. While EMR users value their record systems higher than non-users value the traditional system, EMR systems do not appear to directly impact the other variables. Indirect relationships are suspected and should be tested.

We used a sociotechnical systems analysis to improve the diagnostic testing process in one Midwestern health care organization's outpatient clinics. Outpatient clinic personnel from the clinic were interviewed about their role in the diagnostic testing process. Information on process variances was also collected. A variance matrix and a key variance control chart were constructed for the variances reported by the clinics. Key variances found in the clinic included sample misplaced, sample mislabeled, sample not delivered, sample damaged, request form problems, result tracking breakdown, slow result delivery, result never seen, and patient notification. Based on the variances found in the clinic, recommendations for improvement are given.