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1.  The Value of Human Factors to Medication and Patient Safety in the ICU 
Critical care medicine  2010;38(6 0):S90-S96.
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 (HFE)) is the science and practice of improving human performance. Using decades of HFE research, this paper evaluates a range of common beliefs about patient safety through a human factors lens.
This evaluation demonstrates that HFE provides a framework for understanding safety failures in critical care settings, offers insights in to 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.
PMCID: PMC4455947  PMID: 20502180
Medication errors; Human engineering; Intensive care; Safety
2.  Self-Reported Violations During Medication Administration in Two Pediatric Hospitals 
BMJ quality & safety  2012;21(5):408-415.
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.
To assess the extent of violations in the medication administration process among nurses.
Design, Setting, & Participants
Participants were 199 nurses from two U.S. urban, academic, tertiary care, free-standing pediatric hospitals who worked in: a pediatric intensive care unit (PICU), a hematology-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 7-point 0-6 scale from “not at all” to “a great deal.”
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/Surge 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 3-way interaction among Violation Situation, Step in the process, and Unit, which is explained in detail in the Results.
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 in order to accomplish job tasks.
PMCID: PMC4174297  PMID: 22447818
Patient safety; Compliance; Medication Administration; Violation; Compliance; Human error; Human factors; Medical error; measurement/epidemiology; Patient safety
3.  Automation and adaptation: Nurses’ problem-solving behavior following the implementation of bar coded medication administration technology 
The most common change facing nurses today is new technology, particularly bar coded medication administration technology (BCMA). However, there is a dearth of knowledge on how BCMA alters nursing work. This study investigated how BCMA technology affected nursing work, particularly nurses’ operational problem-solving behavior. Cognitive systems engineering observations and interviews were conducted after the implementation of BCMA in three nursing units of a freestanding pediatric hospital. Problem-solving behavior, associated problems, and goals, were specifically defined and extracted from observed episodes of care. Three broad themes regarding BCMA’s impact on problem solving were identified. First, BCMA allowed nurses to invent new problem-solving behavior to deal with pre-existing problems. Second, BCMA made it difficult or impossible to apply some problem-solving behaviors that were commonly used pre-BCMA, often requiring nurses to use potentially risky workarounds to achieve their goals. Third, BCMA created new problems that nurses were either able to solve using familiar or novel problem-solving behaviors, or unable to solve effectively. Results from this study shed light on hidden hazards and suggest three critical design needs: (1) ecologically valid design; (2) anticipatory control; and (3) basic usability. Principled studies of the actual nature of clinicians’ work, including problem solving, are necessary to uncover hidden hazards and to inform health information technology design and redesign.
PMCID: PMC3891738  PMID: 24443642
Adaptation; problem solving; health information technology; bar coded medication administration (BCMA); nursing
4.  Modeling nurses' acceptance of bar coded medication administration technology at a pediatric hospital 
To identify predictors of nurses' acceptance of bar coded medication administration (BCMA).
Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA.
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).
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).
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.
Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.
PMCID: PMC3534453  PMID: 22661559
Bar coded medication administration systems; BCMA; technology acceptance; TAM; implementation science; pediatric hospital; human factors
5.  Pharmacy workers’ perceptions and acceptance of bar coded medication technology in a pediatric hospital 
The safety benefits of bar-coded medication dispensing and administration technology (BCMA) depend on its intended users favorably perceiving, accepting, and ultimately using the technology.
(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.
Pharmacists and pharmacy technicians at a Midwest US pediatric hospital were surveyed following the hospital’s implementation of a BCMA system. Twenty-nine pharmacists and ten 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.
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.
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.
PMCID: PMC3390462  PMID: 22417887
bar coded medication dispensing and administration systems; BCMA; technology acceptance; pediatric hospital
6.  That’s nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care 
Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses’ perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses’ perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.
PMCID: PMC3113497  PMID: 21686318
health information technology; bar coded medication administration; process change; patient safety; human factors engineering
7.  A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life 
BMJ quality & safety  2011;20(1):15-24.
Nursing workload is increasingly thought to contribute to both nurses’ quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualizing and measuring the effects of workload in health care. In contrast, we conceptualized a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes.
To test this model, we analyzed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care pediatric hospitals.
Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading = .31) and burnout (path loading = .45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading = .25) and medication error likelihood (path loading = 1.04). Job-level workload was not uniquely and significantly associated with any outcomes.
The human factors engineering model of nursing workload was supported by data from two pediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.
PMCID: PMC3058823  PMID: 21228071
workload; mental workload; patient safety; medication error; quality of working life
8.  Effects of mental demands during dispensing on perceived medication safety and employee well being: A study of workload in pediatric hospital pharmacies 
Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes such as job satisfaction.
This study sought to measure the effect of workload on safety and employee outcomes in two pediatric hospitals and to do so using a novel approach to pharmacy workload measurement.
Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, rushing) and internal (concentration, effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression.
Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, rushing) negatively impacted medication safety and employee well being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout, and even had a positive effect on job satisfaction.
Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.
PMCID: PMC3052977  PMID: 21111387
Workload; mental demands; medication error; safety; employee well being; human factors

Results 1-8 (8)