NDLI: Human factors engineering design demonstrations can enlighten your RCA team

Content Provider	PubMed Central
Author	Gosbee, J. Anderson, T.
Abstract	A case study is presented, based on the experience of the US Veterans Affairs health system, which shows the benefits of healthcare personnel understanding human factors engineering (HFE) and how it relates to patient safety. After HFE training, personnel are better able to use a systems-oriented approach during adverse event analysis. Without some appreciation of HFE, the focus of adverse event analyses (e.g. root cause analysis (RCA)) is often misguided towards policies or an individual's shortcomings, leading to ineffective solutions. The case study followed the investigation by an RCA team of a retained sponge following cardiac surgery. The team began with a focus on the specific failings of the surgical nurse and outdated policies. HFE design demonstrations were used to redirect the team's focus to more systems-oriented issues, which could be uncovered even when events appeared to be related to policy or training, and to point them towards examining the design of systems that contributed to the event. The team was thus able to identify design flaws and make improvements to the design of the forms and computer systems that were key to preventing such events from recurring.
Related Links	http://dx.doi.org/10.1136/qhc.12.2.119
Ending Page	121
Page Count	3
Starting Page	119
File Format	PDF
ISSN	14753898
e-ISSN	14753901
Journal	Quality & safety in health care
Issue Number	2
Volume Number	12
Language	English
Publisher	BMJ Group
Publisher Date	2003-04-01
Access Restriction	Open
Rights Holder	BMJ Group
Subject Keyword	Health Policy Research in Higher Education
Content Type	Text
Resource Type	Article
Subject	Health Policy

Sl.	Authority	Responsibilities	Communication Details
1	Ministry of Education (GoI), Department of Higher Education	Sanctioning Authority	https://www.education.gov.in/ict-initiatives
2	Indian Institute of Technology Kharagpur	Host Institute of the Project: The host institute of the project is responsible for providing infrastructure support and hosting the project	https://www.iitkgp.ac.in
3	National Digital Library of India Office, Indian Institute of Technology Kharagpur	The administrative and infrastructural headquarters of the project	Dr. B. Sutradhar bsutra@ndl.gov.in
4	Project PI / Joint PI	Principal Investigator and Joint Principal Investigators of the project	Dr. B. Sutradhar bsutra@ndl.gov.in Prof. Saswat Chakrabarti will be added soon
5	Website/Portal (Helpdesk)	Queries regarding NDLI and its services	support@ndl.gov.in
6	Contents and Copyright Issues	Queries related to content curation and copyright issues	content@ndl.gov.in
7	National Digital Library of India Club (NDLI Club)	Queries related to NDLI Club formation, support, user awareness program, seminar/symposium, collaboration, social media, promotion, and outreach	clubsupport@ndl.gov.in
8	Digital Preservation Centre (DPC)	Assistance with digitizing and archiving copyright-free printed books	dpc@ndl.gov.in
9	IDR Setup or Support	Queries related to establishment and support of Institutional Digital Repository (IDR) and IDR workshops	idr@ndl.gov.in

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