Dr. Ayse P. Gurses of Johns Hopkins University School of Medicine has won the 2014 Liberty Mutual Best Paper Award.

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Scientific Paper Examines Patient Safety and Risks from Technologies in the Healthcare System

April 16, 2014


Institute of Ergonomics and Human Factors Past President, Dr. Richard Graveling and 2014 Liberty Mutual Best Paper Award Winner Ayse P. Gurses of Johns Hopkins University
Institute of Ergonomics and Human Factors
Past President, Dr. Richard Graveling and
Dr. Ayse P. Gurses of Johns Hopkins 
University Schools of Medicine

HOPKINTON, MA – A team of nine researchers received the 2014 Liberty Mutual Award for their scientific paper, “Technologies in the wild (TiW): human factors implications for patient safety in the cardiovascular operating room.”  The paper, published in Ergonomics (Vol. 56, No. 2, pp. 205-219, 2013), provides a richer and more realistic understanding of the potential risks to patient safety introduced by a multitude of technologies in a complex health care work system, specifically a cardiovascular operating room. The award was presented at the 2014 Annual Conference of the Institute of Ergonomics and Human Factors held in April at Grand Harbour Hotel in Southampton, UK.

The Best Paper Award promotes excellence in safety and health research.  The annual award, established in 2005 by the Liberty Mutual Research Institute for Safety and the UK Institute for Ergonomics and Human Factors (formerly the Ergonomics Society), recognizes the paper that best contributes to the advancement of ergonomics.  The editors of Ergonomics, in conjunction with the Institute’s Honors Committee, select the winner from all of the papers published in the journal over the given year.

The winning research team members are Priyadarshini R. Pennathur, PhD of the University of Iowa; David Thompson, DNSc., MS, RN of the Johns Hopkins University Schools of Medicine, Bloomberg Public Health and Nursing;  James H. Abernathy III, MD, MPH, FASE of the  Medical University of South Carolina; the late Elizabeth A. Martinez, MD, MHS of the Massachusetts General Hospital, Harvard Medical School and Johns Hopkins University School of Medicine; Ayse P. Gurses, PhD of Johns Hopkins University Schools of Medicine; Peter J. Pronovost, MD, PhD, FCCM of the Johns Hopkins University School of Medicine: George R. Kim, MD, FAAP of the Johns Hopkins University Schools of Medicine and Nursing; Lisa H. Lubomski, PhD of the Johns Hopkins University School of Medicine; Jill A. Marsteller, PhD, MPP of the  Johns Hopkins University Schools of Medicine and the Bloomberg School of Public Health.

“The paper by Ayse Gurses and her colleagues was selected for the 2014 award against very strong competition,” says Roger Haslam, coordinating editor of Ergonomics.  “We recognized the study as an important inter-disciplinary collaboration, addressing a major issue of contemporary concern.  The editors were particularly impressed with the attempt to study the complexity of multiple operating room technologies in the context of their real world deployment and use.  On behalf of my fellow editors and the IEHF, I would like to offer the authors our warm congratulations on their achievement.”

The winning paper describes technology-related hazards, that is, technologies that could lead to a medical error, in a complex, fast-paced, and high-stakes work environment – the cardiovascular operating room. The paper also examines the possible impact of these hazards on clinician cognition and performance based on an observational study on five large cardiac surgery centers in the USA. 

“Technology is playing an increasingly important role in many safety-critical systems, including health care,” says Dr. Gurses, one of the paper’s authors.  “In the cardiovascular operating room, there are many technology-related safety hazards, which may have negative consequences.”  The paper indicates that these technology-related hazards are multidimensional, complex and require in-depth and interdisciplinary approaches for understanding their impact. The interaction of poorly designed technologies and physical spaces, organizational constraints and functional capability have the potential to multiply latent risks in the use of cardiovascular operating room technologies.

For the investigation, researchers conducted an in-depth data analysis of technology-related hazards.   This prospective study applied multiple methods aimed at identifying risks to patient safety in cardiovascular operating rooms.  The researchers focused specifically on technology-related hazards/risks.  The resulting data were collected during two 2.5 day visits to five sites, and included observational data from 20 cardiac surgeries (160 hours), follow-up questions to clarify and obtain more detailed information on the observations, and photographing of physical layouts and technologies for detailed analysis by human factors experts.

The data revealed four types of technology-related hazards:

  1. Hazards due to technology design (e.g., user interface not providing at-a-glance view of critical information).
  2. Organizational factors (e.g., considerably out-dated heart-lung equipment (for cardiac  bypass) being used due to financial constraints).
  3. Physical/environmental factors (e.g., surgical suction canisters – important to check for blood loss during certain types of procedures- are always behind the electrical arm and not visible to anesthesia).
  4. Functional status of a particular technology (i.e., functioning or non-functioning).

The researchers also identified 21 types of negatively affected cognitive processes (e.g., reduced attention, reduced vigilance, high workload, etc.).  The processes when combined with technology-related hazards may potentially reduce human performance and increase the possibility of human errors.

The paper suggests that manufacturers should design safety features into technologies instead of transferring the burden of troubleshooting technologies to the health care providers.  “To improve patient safety in technology-rich environments, it’s important to design technologies based on a user-centered approach, coupled with iterative and rigorous testing and evaluation,” says Dr. Gurses.  “Our paper examines multiple technologies simultaneously in the context of their use, and their interactions with each other, and with other components of the work system (e.g., tasks, physical layout, etc.) to provide a comprehensive and realistic understanding of technology-related safety hazards.”

“My co-authors and I are greatly honored and proud to win this prestigious award,” says Dr. Gurses.  “I am particularly excited because the award is an excellent indication of how much the field of human factors/ergonomics has to offer to improve health care quality and safety and the importance of close, interdisciplinary collaboration between clinicians and human factors/ergonomics experts.”

About Liberty Mutual Research Institute for Safety

Owned and operated by Liberty Mutual Insurance, the Liberty Mutual Research Institute for Safety (www.libertymutualgroup.com/researchinstitute) is an internationally recognized safety and health research facility. Through laboratory and field-based investigations, the Research Institute seeks to advance scientific, business-relevant knowledge in workplace and highway safety and disability. Research findings, published in the open, peer reviewed literature, are shared with the worldwide health and safety community and are often used to develop recommendations, guidelines, and interventions to help reduce injury and disability.

About Liberty Mutual Insurance

“Helping people live safer, more secure lives” since 1912, Boston-based Liberty Mutual Insurance is a diversified global insurer and the third largest property and casualty insurer in the U.S. based on 2013 direct premiums written, as reported by the National Association of Insurance Commissioners.

Liberty Mutual Insurance also ranks 81st on the Fortune 100 list of largest corporations in the U.S. based on 2012 revenue.  As of December 31, 2013, Liberty Mutual Insurance had $121.2 billion in consolidated assets, $102.2 billion in consolidated liabilities and $38.5 billion in annual consolidated revenue.

Liberty Mutual Insurance offers a wide range of insurance products and services, including personal automobile, homeowners, workers compensation, property, commercial automobile, general liability, global specialty, group disability, reinsurance and surety. Liberty Mutual Insurance (www.libertymutualinsurance.com) employs over 50,000 people in more than 900 offices throughout the world.

About Institute of Ergonomics and Human Factors

The Institute of Ergonomics and Human Factors (www.iehf.org), founded in 1949, is the professional body for researchers and practitioners in the field of ergonomics, with an international membership in excess of 1700.  Its aim is to promote the awareness, education and application of ergonomics in industry, commerce, public sector and government.

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