Purpose: The aims of this study were to investigate how a variety of research methods is commonly employed to study technology and practitioner cognition. User-interface issues with infusion pumps were selected as a case because of its relevance to patient safety. Methods: Starting from a Cognitive Systems Engineering perspective, we developed an Impact Flow Diagram showing the relationship of computer technology, cognition, practitioner behavior, and system failure in the area of medical infusion devices. We subsequently conducted a systematic literature review on user-interface issues with infusion pumps, categorized the studies in terms of methods employed, and noted the usability problems found with particular methods. Next, we assigned usability problems and related methods to the levels in the Impact Flow Diagram. Results: Most study methods used to find user interface issues with infusion pumps focused on observable behavior rather than on how artifacts shape cognition and collaboration. A concerted and theorydriven application of these methods when testing infusion pumps is lacking in the literature. Detailed analysis of one case study provided an illustration of how to apply the Impact Flow Diagram, as well as how the scope of analysis may be broadened to include organizational and regulatory factors. Conclusion: Research methods to uncover use problems with technology may be used in many ways, with many different foci. We advocate the adoption of an Impact Flow Diagram perspective rather than merely focusing on usability issues in isolation. Truly advancing patient safety requires the systematic adoption of a systems perspective viewing people and technology as an ensemble, also in the design of medical device technology.
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BackgroundOcclusions of intravenous (IV) tubing can prevent vital and time-critical medication or solutions from being delivered into the bloodstream of patients receiving IV therapy. At low flow rates (≤ 1 ml/h) the alarm delay (time to an alert to the user) can be up to 2 h using conventional pressure threshold algorithms. In order to reduce alarm delays we developed and evaluated the performance of two new real-time occlusion detection algorithms and one co-occlusion detector that determines the correlation in trends in pressure changes for multiple pumps.MethodsBench-tested experimental runs were recorded in triplicate at rates of 1, 2, 4, 8, 16, and 32 ml/h. Each run consisted of 10 min of non-occluded infusion followed by a period of occluded infusion of 10 min or until a conventional occlusion alarm at 400 mmHg occurred. The first algorithm based on binary logistic regression attempts to detect occlusions based on the pump’s administration rate Q(t) and pressure sensor readings P(t). The second algorithm continuously monitored whether the actual variation in the pressure exceeded a threshold of 2 standard deviations (SD) above the baseline pressure. When a pump detected an occlusion using the SD algorithm, a third algorithm correlated the pressures of multiple pumps to detect the presence of a shared occlusion. The algorithms were evaluated using 6 bench-tested baseline single-pump occlusion scenarios, 9 single-pump validation scenarios and 7 multi-pump co-occlusion scenarios (i.e. with flow rates of 1 + 1, 1 + 2, 1 + 4, 1 + 8, 1 + 16, and 1 + 32 ml/h respectively). Alarm delay was the primary performance measure.ResultsIn the baseline single-pump occlusion scenarios, the overall mean ± SD alarm delay of the regression and SD algorithms were 1.8 ± 0.8 min and 0.4 ± 0.2 min, respectively. Compared to the delay of the conventional alarm this corresponds to a mean time reduction of 76% (P = 0.003) and 95% (P = 0.001), respectively. In the validation scenarios the overall mean ± SD alarm delay of the regression and SD algorithms were respectively 1.8 ± 1.6 min and 0.3 ± 0.2 min, corresponding to a mean time reduction of 77% and 95%. In the multi-pump scenarios a correlation > 0.8 between multiple pump pressures after initial occlusion detection by the SD algorithm had a mean ± SD alarm delay of 0.4 ± 0.2 min. In 2 out of the 9 validation scenarios an occlusion was not detected by the regression algorithm before a conventional occlusion alarm occurred. Otherwise no occlusions were missed.ConclusionsIn single pumps, both the regression and SD algorithm considerably reduced alarm delay compared to conventional pressure limit-based detection. The SD algorithm appeared to be more robust than the regression algorithm. For multiple pumps the correlation algorithm reliably detected co-occlusions. The latter may be used to localize the segment of tubing in which the occlusion occurs.
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Purpose – As hospitals are now being designed with an increasing number of single rooms or cubicles, the individual preference of patients with respect to social contact is of great interest. The purpose of this study is to gain a better understanding of the experience of patients in an outpatient infusion center.Design/methodology/approach – A total of 29 semi-structured interviews were conducted, transcribed and analyzed by using direct content analysis.Findings – Findings showed that patients perceived a lack of acoustic privacy and therefore tried to emotionally isolate themselves or withheld information from staff. In addition, patients complained about the sounds of infusion pumps, but they were neutral about the interior features. Patients who preferred non-talking desired enclosed private rooms and perceived negative distraction because ofspatial crowding. In contrast, patients who preferred talking, or had no preference, desired shared rooms and perceived positive distraction because of spatial crowding.Research limitations/implications – In conclusion, results showed a relation between physical aspects (i.e. physical enclosure) and the social environment.Practical implications – The findings allow facility managers to better understand the patients’ experiences in an outpatient infusion facility and to make better-informed decisions. Patients with different preferences desired different physical aspects. Therefore, nursing staff of outpatient infusion centers should assess the preferences of patients. Moreover, architects should integrate different typesof treatment places (i.e. enclosed private rooms and shared rooms) in new outpatient infusion centers to fulfill different preferences and patients should have the opportunity to discuss issues in private with nursing staff.Originality/value – This study emphasizes the importance of a mix of treatment rooms, while new hospital designs mainly include single rooms or cubicles.
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Background: Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systematically. Objectives: To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods: A cross-sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used. Results: We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation's protocol. Conclusions: Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.
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Background Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systenaticaly. Objectives To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods A cross- sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used. Results We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation’s protocol. Conclusions Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.
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Introduction: Nursing education traditionally teaches skill acquisition in isolated practice drills and guided by step-by-step protocols. While these approaches may seem to provide a solid foundation, they do not adequately bridge the gap between a controlled learning environment and the reality of nursing practice. The constraints-led approach (CLA) is an applied theory, which explains that skill acquisition is a process of adjusting to the characteristics of a situation, instead of reproducing isolated, “ideal” movements out of context. Given that CLA has gained recognition as an effective learning method in various fields, it is worth investigating how CLA can be implemented for skill acquisition in nursing education. Methods: To gain insight into student experiences of several CLA-exercises, an explorative qualitative design was used. Ten longitudinal focus groups with nursing students (n = 11) were performed to gain deeper understanding of students’ experiences with an education course in which several “CLA-exercises” were integrated. In addition, the teachers (n = 3) involved were interviewed after the course was completed. Results: The students experienced the education course as enjoyable, challenging and reality-based. Also, the exercises motivated students to keep practicing. The students further appreciated the room for autonomy and self-organization. The teachers expressed enthusiasm for CLA-inspired education, noting the benefits of varied methods and the need for expert feedback and well-working practice materials. Conclusion: Both students and teachers felt confident that the students who completed this course were ready to apply the learned skills under supervision in clinical practice.
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Objective: Post-mortem computed tomography (PMCT) is an established method for disease, complications, and cause of death determination in both clinical and forensic cases. By adding intravascular infusion of contrast medium, computed tomography angiography (PMCTA) provides additional information on vascular structures and hemorrhages. When easily applicable and low in costs, this technique would be more frequently applied and of additional value to clinical and educational purposes, particularly in forensic scientific context. Materials and Methods: PMCTA was performed on 10 bodies of the anatomy department. First, a metal T-piece was inserted into the femoral artery as part of standard practice for conservation. Secondly, surplus contrast medium with sodium chloride was infused into the body through a catheter tube set attached to the metal T-piece, using a readily available enteroclysis pump from our radiology department. Results: With added costs of approximately € 266 (personnel and materials) and an additional procedure time of 15-20 minutes, successful infusion of contrast mixture was achieved with the enteroclysis pump. Partial or complete opacification was measured in 89% of arteries, with enhancement of soft tissue visualization. Conclusion: This study successfully evaluated an inexpensive and easy to use method to perform PMCTA for post-mortem investigations.
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Background: To use advanced medical technologies (AMTs) correctly and safely requires both specialist knowledgeand skills, and an awareness of risks and how those can be minimized. Reporting safety concerns aboutAMTs in home care can contribute to an improved quality of care. The extent to which a health care organizationhas integrated the reporting, evaluation and learning from incidents is a key element of that organization’spatient safety culture.Objectives: To explore nurses’ experiences regarding the education followed in the use of AMTs in the homesetting, and their organizations’ systems of reporting.Design: Descriptive cross-sectional design.Methods: 209 home care nurses from across the Netherlands who worked with infusion therapy, parenteralnutrition and/or morphine pumps responded to the online questionnaire between July 2018 and February 2019.The analysis of the data was mainly descriptive.Results: Educational interventions that are most often used to learn how to use AMTs were, as an average over thethree AMTs, instruction by a nurse (71%), practical training in the required skills (71%) and acquiring informationto increase theoretical knowledge (69%). Considerable attention is paid to patient safety (88%) and thehome setting (89%). However, a substantial proportion of the nurses (up to 29%) use AMTs even though they hadnot been tested on their skills. 95% of the respondents were well acquainted with the incident reporting protocolof their organization, but only 49% received structural or regular feedback on any actions taken as a result ofevent reporting.Conclusions: This study revealed aspects of nurses’ education that imply risk factors for patient safety. Practicaltraining is not always given, additional or retraining is often voluntary, and the required skills are not alwaystested. However, the results show that nurses do have a good awareness of patient safety. Incidents are mainlydiscussed within the team, but less at the organizational level.
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BackgroundTo use advanced medical technologies (AMTs) correctly and safely requires both specialist knowledge and skills, and an awareness of risks and how those can be minimized. Reporting safety concerns about AMTs in home care can contribute to an improved quality of care. The extent to which a health care organization has integrated the reporting, evaluation and learning from incidents is a key element of that organization's patient safety culture.ObjectivesTo explore nurses' experiences regarding the education followed in the use of AMTs in the home setting, and their organizations' systems of reporting.DesignDescriptive cross-sectional design.Methods209 home care nurses from across the Netherlands who worked with infusion therapy, parenteral nutrition and/or morphine pumps responded to the online questionnaire between July 2018 and February 2019. The analysis of the data was mainly descriptive.ResultsEducational interventions that are most often used to learn how to use AMTs were, as an average over the three AMTs, instruction by a nurse (71%), practical training in the required skills (71%) and acquiring information to increase theoretical knowledge (69%). Considerable attention is paid to patient safety (88%) and the home setting (89%). However, a substantial proportion of the nurses (up to 29%) use AMTs even though they had not been tested on their skills. 95% of the respondents were well acquainted with the incident reporting protocol of their organization, but only 49% received structural or regular feedback on any actions taken as a result of event reporting.ConclusionsThis study revealed aspects of nurses' education that imply risk factors for patient safety. Practical training is not always given, additional or retraining is often voluntary, and the required skills are not always tested. However, the results show that nurses do have a good awareness of patient safety. Incidents are mainly discussed within the team, but less at the organizational level.
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Purpose – In the domain of healthcare, both process efficiency and the quality of care can be improved through the use of dedicated pervasive technologies. Among these applications are so-called real-time location systems (RTLS). Such systems are designed to determine and monitor the location of assets and people in real time through the use of wireless sensor networks. Numerous commercially available RTLS are used in hospital settings. The nursing home is a relatively unexplored context for the application of RTLS and offers opportunities and challenges for future applications. The paper aims to discuss these issues. Design/methodology/approach – This paper sets out to provide an overview of general applications and technologies of RTLS. Thereafter, it describes the specific healthcare applications of RTLS, including asset tracking, patient tracking and personnel tracking. These overviews are followed by a forecast of the implementation of RTLS in nursing homes in terms of opportunities and challenges. Findings – By comparing the nursing home to the hospital, the RTLS applications for the nursing home context that are most promising are asset tracking of expensive goods owned by the nursing home in orderto facilitate workflow and maximise financial resources, and asset tracking of personal belongings that may get lost due to dementia. Originality/value – This paper is the first to provide an overview of potential application of RTLS technologies for nursing homes. The paper described a number of potential problem areas that can be addressed by RTLS. Published by Emerald Publishing Limited Original article: https://doi.org/10.1108/JET-11-2017-0046 For this paper Joost van Hoof received the Highly Recommended Award from Emerald Publishing Ltd. in October 2019: https://www.emeraldgrouppublishing.com/authors/literati/awards.htm?year=2019
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