A Human Factors and Systems Engineering Approach for Understanding the Diagnostic Process and Associated Safety Hazards in the Emergency Department

用于了解急诊科诊断过程和相关安全隐患的人为因素和系统工程方法

• 批准号: 10252807
• 负责人: AYSE PINAR GURSES
• 金额: $ 35万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-09-30 至 2023-09-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10252807
• 关键词: Human; Factors; Systems; Engineering; Approach

Diagnostic errors are common, deadly, and costly. Twelve million Americans annually experience diagnostic error in ambulatory care, including in Emergency Department (EDs), over half of these with potential for harm. ED clinical practice is especially prone to diagnostic error as a sociotechnical work system that is fast-paced, high-stakes, highly adaptive and complex. The 2016 National Academy of Medicine (NAM) report was an urgent call for more research regarding diagnostic safety, making particular reference to the ED. ED diagnosis is cognitively-intense work, distributed across team members who may or may not be co-located. There is very limited understanding of the salient `real-time' details of the ED diagnostic process and associated performance shaping factors on the work system. Without structured in-depth analysis of ED diagnosis occurring as part of `real-time ED work,' that is “work-as-done,” we will continue the struggle with the design of effective, sustainable interventions to improve diagnostic safety. Accordingly, we are proposing a 3-year, multi- site, multi-method field study in the ED based on a sociotechnical systems approach and a macrocognition framework, which is the study of cognitive tasks that characterize how people think in natural settings. We have 3 specific aims: (1) AIM 1. To understand provider (physician and advanced practice provider) work involved in ED diagnosis and identify associated performance shaping factors. (2) AIM 2. To understand collaborative (team-oriented) work involved in ED diagnosis and identify associated performance shaping factors. (3) AIM 3. To conduct a proactive risk assessment of the diagnostic process in the ED. AIM 1 and AIM 2 will be achieved by conducting in-depth qualitative studies using a variety of data collection methods (observations, interviews) and cognitive task analyses techniques. Data analysis will produce a range of outputs such as process maps, macrocognitive and procedural tasks involved in diagnosis, information flow diagrams, role network graphs, among others. AIM 3 will use two complementary proactive risk assessment methods to assess failure modes and performance shaping factors and to identify possible interventions to improve ED diagnostic safety: (1) Health Care Failure Mode and Effect Analysis (HFMEA); (2) Functional Resonance Analysis Method (FRAM) Based “What-if” Risk Analysis. Additionally, we will develop a research methods compendium/guide for those interested in conducting similar research on diagnostic safety. The study will be conducted in 3 different EDs (urban, suburban, rural) that serve patients from 6 AHRQ priority population groups. The research team is interdisciplinary, composed of internationally known experts in patient safety, human factors, systems engineering, cognitive psychology, communication, emergency medicine, and nursing. The study is innovative due to its lens on ED diagnostic process as a whole, its use of human factors- based conceptual approaches, its investigation of the ED team's role in the diagnosis, and its use of a variety of cognitive task analysis techniques and proactive risk assessment methods.

诊断错误是常见的、致命的和代价高昂的。每年有1200万美国人被诊断为 门诊护理中的错误，包括急诊科(EDS)，其中一半以上有潜在的伤害。 急诊科临床实践特别容易出现诊断错误，因为这是一个快节奏的社会技术工作系统， 高风险、高度适应性和复杂性。2016年美国国家医学科学院(NAM)报告是一份 紧急呼吁进行更多关于诊断安全性的研究，特别是提到急诊室。ED诊断 是认知密集型工作，分布在团队成员之间，他们可能在一起，也可能不在一起。有非常多的 对ED诊断过程和相关的显著“实时”细节的了解有限 绩效塑造因素对工作体系的影响。缺乏对ED诊断的结构化深入分析 作为“实时教育工作”的一部分，也就是“完成工作”，我们将继续努力设计 有效、可持续的干预措施，以提高诊断安全性。因此，我们提议一项为期3年、多年的- 基于社会技术系统方法和宏观认知的教育部门现场多方法实地研究 框架，这是对认知任务的研究，这些任务表征了人们在自然环境中的思维方式。我们 有3个具体目标：(1)目标1.了解提供者(医生和高级实践提供者)的工作 参与勃起功能障碍的诊断并确定相关的绩效塑造因素。(2)目的2.了解 参与ED诊断和确定相关绩效形成的协作(面向团队)工作 各种因素。(3)目的3.对急诊室的诊断过程进行积极的风险评估。 目标1和目标2将通过使用各种数据进行深入的定性研究来实现 收集方法(观察法、访谈法)和认知任务分析技术。数据分析将 产生一系列输出，如流程图、诊断中涉及的宏观认知和程序性任务， 信息流图表、角色网络图表等。目标3将使用两个互补的主动 风险评估方法，用于评估故障模式和性能形成因素，并确定可能的 提高ED诊断安全性的干预措施：(1)医疗服务失效模式及效果分析(HFMEA)；(2) 基于功能共振分析方法(FRAM)的假设风险分析。此外，我们还将开发一种 研究方法概要/指南，供那些有兴趣进行类似诊断安全性研究的人使用。 这项研究将在3家不同的急诊室(城市、郊区和农村)进行，这些急诊室为来自6个AHRQ优先事项的患者提供服务 人口群体。研究团队是跨学科的，由国际知名的患者专家组成。 安全、人为因素、系统工程、认知心理学、通信、急救医学和 护士。这项研究具有创新性，因为它将ED诊断过程作为一个整体来看待，它使用了人为因素-- 基于概念的方法，它对急诊室团队在诊断中的作用的调查，以及它对各种 认知任务分析技术和主动风险评估方法。