Accounting for memes in sociotechnical systems: extending the abstraction hierarchy to consider cognitive objects

Work domain analysis (WDA) is used to model the functional structure of sociotechnical systems (STS) through the abstraction hierarchy (AH). By identifying objects, processes, functions and measures that support system purposes, WDA reveals constraints within the system. Traditionally, the AH describes system elements at the lowest level of abstraction as physical objects. Multiple analyses of complex systems reveal that many include objects that exist only at a conceptual level. This paper argues that, by extending the AH to include cognitive objects, the analytical power of WDA is extended, and novel areas of application are enabled. Three case studies are used to demonstrate the role that cognitive objects play within STS. It is concluded that cognitive objects are a valid construct that offer a significant enhancement of WDA and enable its application to some of the world’s most pressing problems. Implications for future applications of WDA and the AH are discussed.

Practitioner summary: Some sociotechnical systems include memes as part of their functional structure. Three case studies were used to evaluate the utility of introducing cognitive objects alongside physical ones in work domain analysis, the first phase of cognitive work analysis. Including cognitive objects increases the scope and accuracy of work domain analysis.     

Micro- and macroergonomic changes in mental workload and medication safety following the implementation of new health IT

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 industryDesigners 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.     

Case studies of IT sophistication in nursing homes: A mixed method approach to examine communication strategies about pressure ulcer prevention practices

Most nursing homes lack information technology (IT) for supporting clinical work in spite of its potential to improve the safety, quality, and efficiency of nursing home care in the United States. Increased attention to medical error and concern for patient safety have prompted general recommendations to develop sophisticated technologies to support clinical decision making at the point of care, to promote data standards in electronic records, and to develop systems that communicate with each other. However, little is known about what IT applications best support communication and risk assessment practices to improve resident outcomes in nursing homes. Thus, the overall aim of this study was to evaluate how differences in IT sophistication in nursing homes impact communication and use of technology related to skin care and pressure ulcers. We used a mixed method approach to conduct case studies on two nursing homes – one with high IT sophistication and one with low IT sophistication. Observational analysis and social network analysis were used to identify patterns in communication types and locations; also, focus groups were conducted to explore communication strategies used by Certified Nursing Assistants (CNAs) to support pressure ulcer prevention practices. Overall, results from social network analysis of observational data indicate that direct interactions between CNAs and registered nurses (RNs) or licensed practical nurses (LPNs) were more frequent in the low IT sophistication home and occurred in more centralized locations (e.g. the nursing station) compared to the high IT sophistication home. Moreover, these findings are supported by focus group results, which indicate that the high IT sophistication home had more robust and integrated communication strategies (both IT and non IT) that may allow for interactions throughout the facility and require less frequent face to face interactions between CNAs and RNs or LPNs to verify orders or report patient status. Results from this study provide insight into the design and assessment of different forms of communication to support clinical work in NHs.Relevance to industryNurses bear great burdens for nursing home care; yet, issues persist with poor quality, variable performance of caregiving, and lack of implementation of proven care interventions. One new hope for improvement in nursing home care is the introduction of IT to improve communication, clinical decision-making, and quality of care.     

Patient safety, systems design and ergonomics

The complexity of the health care environments necessitates an holistic and systematic ergonomics approach to understand the potential for accidents and errors to occur. The health service is also a socio-technical system, and design needs must be met within this context. This paper aims to present the design challenges and emphasises the specialised needs of the health care sector, when dealing with patient safety. It also provides examples of approaches and methods that ergonomists can bring to help inform our knowledge of these systems and the potential towards improving their safety. Mapping workshops provide an example of such methods. Results from these are used to illustrate how the knowledge base required for better design requirements can be generated. The workshops were developed specifically to help improve the design of medication packaging and thereby reduce the probability of medication error. The issues raised are now the subject of further research, design requirements guidance and new design concepts. The paper illustrates the need to engage with the design community and, through the use of robust scientific methods, to generate appropriate design requirements.     

Improving cardiac surgical care: A work systems approach

Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.     

Using a checklist-based electronic calculation aid and contextual cues to assist medication dose calculation and calculation resumption after interruptions

ObjectivesTo examine whether (1) the use of a checklist-based electronic calculation aid enhanced medication dose calculation and reduced the negative effects of interruptions on calculation, and (2) the use of contextual cues facilitated the resumption of calculation after an interruption.MethodsSixty students in healthcare majors participated in two computer-based laboratory experiments. Experiment 1 examined the effects of the calculation aid and interruptions on calculation error rate, calculation completion time, and perception outcomes. Experiment 2 assessed the effects of contextual cues on resumption error rate, calculation error rate, calculation completion time, and perception outcomes.ResultsIn Experiment 1, calculation error rates were lower for participants who received the calculation aid versus those who did not, and for uninterrupted calculations versus interrupted calculations, although the differences were not statistically significant.The participants spent significantly less time completing the calculation task with the use of the calculation aid than without the use of the calculation aid, and in the case without interruptions than in the case with interruptions. In Experiment 2, the use of contextual cues associated with previous actions significantly reduced the resumption error rate and the completion time of the medication dose calculation. Both experiments showed that the use of the calculation aid and contextual cues was associated with positive attitudes toward the aid and cues, reduced mental effort, and/or higher confidence in task performance.ConclusionsThe use of the checklist-based electronic calculation aid and contextual cues facilitated medication dose calculation and resumption after interruptions and thus has the potential to improve medication safety and work efficiency in healthcare.     

Macroergonomics and patient safety: The impact of levels on theory, measurement, analysis and intervention in patient safety research

The study and practice of patient safety has seen a surge over the last 10 years. New resident training and staffing policies, health information technologies, error reporting systems, team models of care, training methods, patient involvement, information handoff strategies, just cultures, and many other interventions have been mandated or attempted to improve the safety of patient care. While some of these interventions focus on individual providers and others focus on organization-level changes, little, if any, patient safety research has purposefully sought to understand how variables at different levels, such as the provider level or organization level, interact to impact patient safety outcomes such as errors, adverse drug events, or patient harm. Looking at relationships across levels is important because adverse events might be related to variables at different levels; consider that adverse events may be nested within patients, patients nested within nurses and physicians, nurses and physicians nested within shifts, shifts nested within hospital units, and so forth. Because these nested levels exist, they may exert as yet untested influence on the levels below. In this paper the impact of levels on theory, measurement, analysis and intervention in patient safety research is discussed.     

A work domain analysis framework for modelling intensive care unit patients

Work domain analysis (WDA) has been applied to a range of complex work domains, but few WDAs have been undertaken in medical contexts. One pioneering effort suggested that clinical abstraction is not based on means-ends relations, whereas another effort downplayed the role of bio-regulatory mechanisms. In this paper it is argued that bio-regulatory mechanisms that govern physiological behaviour must be part of WDA models of patients as the systems at the core of intensive care units. Furthermore it is argued that because the inner functioning of patients is not completely known, clinical abstraction is based on hypothetico-deductive abstract reasoning. This paper presents an alternative modelling framework that conforms to the broader aspirations of WDA. A modified version of the viable systems model is used to represent the patient system as a nested dissipative structure while aspects of the recognition primed decision model are used to represent the information resources available to clinicians in ways that support if...then conceptual relations. These two frameworks come together to form the recursive diagnostic framework, which may provide a more appropriate foundation for information display design in the intensive care unit.Abbreviations ADS Abstraction decomposition space - DST Dissipative structures theory - HIV/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome - ICU Intensive care unit - RDF Recursive diagnostic framework - RPD Recognition primed decision model - R-VSM Revised viable systems model - VSM Viable systems model - WDA Work domain analysis     

Assessment of patient safety research from an organizational ergonomics and structural perspective

The aim of this study is to review patient safety improvement initiatives within a conceptual framework that builds upon principles of organizational ergonomics and emphasizes structural factors that influence patient safety. The literature review included 131 English language published studies of patient safety improvement strategies extracted using Medline, Ovid Healthstar, PubMed and CINAHL searches. Keywords for the search included: ‘patient safety’; ‘medical errors’; ‘adverse event’; ‘iatrogenic’; and truncated options for ‘improve’. The multilevel, hierarchical framework offered in this paper integrates quality management principles and organizational ergonomics theory and organizes patient safety initiatives according to sociotechnical system elements within three structural levels: health policies and associated health care organizations; health care delivery organizations; and health care microsystems. Utilizing the conceptual framework, this review of patient safety improvement initiatives highlights the need for consideration of the impact of all improvement proposals on each structural component within health care systems. The review also supports the need for patient safety research to evolve from exploratory, 1-D reporting to multi-level, integrated research.     

Boundary, Purpose, and Values in Work-Domain Models: Models of Naval Command and Control

This paper presents an application of work-domain analysis (WDA) to the domain of the command and control of a multipurpose naval frigate—the Canadian Halifax Class frigate. This represents an application of this approach to a real system and, to the authors' knowledge, is the most extensive WDA of a naval work domain. In particular, and in contrast to other applications of cognitive work analysis, the authors extended the basic WDA framework to handle a multipurpose, loosely bound work domain. In addition, the naval domain is value driven, and this affects naval decision making. Values were incorporated as a social organizational analysis into the work-domain model and were represented as a type of soft constraint. A total of 38 submodels of the work domain were developed, whose primary models are discussed in this paper. From these models, 132 information requirements were extracted, substantiating that WDA is a worthwhile technique for supporting interface design. This paper makes a theoretical contribution by extending the WDA framework and a practical contribution by demonstrating the usefulness of the framework in a real design context. This paper concentrates on presenting WDA as a process, not as a finished product, showing intermediate levels of models and the design requirements that can be extracted from the early stages of the WDA.     

Integrated safety analysis of requirements specifications

This paper describes an integrated approach to safety analysis of software requirements and demonstrates the feasibility and utility of applying the individual techniques and the integrated approach on the requirements specification of a guidance system for a high-speed civil transport being developed at NASA Ames. Each analysis found different types of errors in the specification; thus together the techniques provided a more comprehensive safety analysis than any individual technique. We also discovered that the more the analyst knew about the application and the model, the more successful they were in finding errors. Our findings imply that the most effective safety-analysis tools will assist rather than replace the analyst. A shorter version of this paper appeared in the Proceedings of the 3rd International Symposium on Requirements Engineering, Annapolis, Maryland, January 1997. The research described has been partly funded by NASA/Langley Grant NAG-1-1495, NSF Grant CCR-9396181, and the California PATH Program of the University of California     

The investigation of human error analysis in adverse drug events in Taiwan—From the perspective of causality assessment

The goal of this study is to analyze the adverse drug events, using the human factors analysis and classification system (HFACS), and to identify the causality between the error factors. Twenty‐five cases related to medication errors were identified. Seven experts were recruited to form an expert team for this study. The HFACS and root cause analysis were utilized in this study to identify the causal factors and the root causes of medication errors. The frequency of each error factor was recorded, and odds ratio was applied to measure the strength of the relevance of the error factors between adjacent levels of the HFACS. The results showed that 222 errors were identified and the main pathways and subpathways of medication errors from Level 4 to Level 1 of the HFACS were arranged in this study. According to the results, the deficiencies in organizations could be the main reasons causing adverse drug events in Taiwan.     

医院消杀机器人作业安全与交互设计策略

作业安全与设计质量对提高医院公共环境消杀机器人"人机系统"运行效率具有关键作用.以人因工程学、交互科学、认知科学理论为视角,探究医院消杀机器人作业安全与交互设计策略.采用层次任务与表格任务结合H TA-T分析法,构建消杀作业任务流程,剖析作业流程中典型安全事故及其致因逻辑,基于工作域分析法(WDA)对消杀作业约束条件进...     

基于系统思维的软件安全性需求开发框架

糟糕的软件需求是导致安全性关键系统发生灾难性事故的最主要原因。为解决需求开发问题,建构了一个系统建模与系统分析相结合、基于系统思维的软件安全性需求开发框架。针对系统模型的特定等级特定领域,提出了集成安全性分析的需求开发方法。该方法既能最大限度地约束安全性需求缺陷,防止其向同一分析等级内的其它领域或下一分析等级传播,并尽早重新生成安全性需求,又能够不断生成证据,支持安全性论据的构建。     

Understanding challenges in the front lines of home health care: A human-systems approach

A human-systems perspective is a fruitful approach to understanding home health care because it emphasizes major individual components of the system – persons, equipment/technology, tasks, and environments – as well as the interaction between these components. The goal of this research was to apply a human-system perspective to consider the capabilities and limitations of the persons, in relation to the demands of the tasks and equipment/technology in home health care. Identification of challenges and mismatches between the person(s) capabilities and the demands of providing care provide guidance for human factors interventions. A qualitative study was conducted with 8 home health Certified Nursing Assistants and 8 home health Registered Nurses interviewed about challenges they encounter in their jobs. A systematic categorization of the challenges the care providers reported was conducted and human factors recommendations were proposed in response, to improve home health. The challenges inform a human-systems model of home health care.     

A critical review of the systems approach within patient safety research

The application of concepts, theories and methods from systems ergonomics within patient safety has proved to be an expanding area of research and application in the last decade. This paper aims to take a step back and examine what types of research have been conducted so far and use the results to suggest new ways forward. An analysis of a selection of the patient safety literature suggests that research has so far focused on human error, frameworks for safety and risk and incident reporting. The majority of studies have addressed system concerns at an individual level of analysis with only a few analysing systems across multiple system boundaries. Based on the findings, it is argued that future research needs to move away from a concentration on errors and towards an examination of the connections between systems levels. Examples of how this could be achieved are described in the paper. The outcomes from the review of the systems approach within patient safety provide practitioners and researchers within health care (e.g. the UK National Health Service) with a picture of what types of research are currently being investigated, gaps in understanding and possible future ways forward.     

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.

Relevance to industry

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.     

Toward a theoretical approach to medical error reporting system research and design

The release of the Institute of Medicine (Kohn et al., 2000) report "To Err is Human", brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation.     

Patient safety during medication administration: the influence of organizational and individual variables on unsafe work practices and medication errors

Medication errors are a leading cause of unintended harm to patients, both in Australia and internationally, and there is now a concerted attempt to identify and correct individual and workplace factors that encourage medication errors. The current study used structural equation modelling to measure organizational climate and to test a model with hypothesized links between climate and unsafe medication administration behaviours. The study also examined the possible mediating role of stress and morale. Data were collected from 176 nurses working in rural areas in Australia. The model provided a reasonable fit to the data with organizational climate accounting for 39% of the variance in individual distress, which in turn explained 7% of the variance in self-reported violations. The only variable that made a direct contribution to errors was violations, which accounted for 24% of the variance in medication errors. These findings highlight the importance of monitoring the state of the whole health system. Deficiencies at the organizational level affect the psychological well-being of hospital employees, and distressed employees are more likely to engage in substandard work practices that ultimately endanger the patients under their care.     

基于AADL的混合关键系统随机错误与突发错误安全性分析

许多复杂的嵌入式系统都是混合关键系统(mixed-criticality system,简称MCS).MCS通常需要在指定的关键性(criticality)等级状态下运行,但是它们可能会受到一些危害的影响,这些危害可能会导致随机错误和突发错误,进一步导致执行线程中止,甚至导致系统故障.目前的研究仅集中于对MCS的可调度性分析,未能进一步分析系统安全性,未能考虑线程之间的依赖关系.本文以随机错误和突发错误为研究对象,提出一种集成故障传播分析的基于架构的MCS安全分析方法.使用架构分析和设计语言(Architecture Analysis and Design Language,简称AADL)刻画构件依赖关系.为了弥补AADL的不足,创建新的AADL属性(AADL突发错误属性),并提出新的线程状态机(突发错误行为线程状态机)语义来描述带有突发错误的线程执行过程.为了将概率模型检查应用于安全分析,提出模型转换规则和组装方法,从AADL模型推导出PRISM模型.建立了两个公式,分别获得定量安全属性以验证故障发生的概率,以及定性安全属性以生成相应的正例来求出故障传播路径来进行故障传播分析.最后,以动力艇自动驾驶仪(power boat autopilot,简称PBA)系统为例,验证了该方法的有效性.