(left to right) Research Institute Director, Y. Ian Noy, Ph.D.; award winners Priyadarshini R. Pennathur, Ph.D. and Ayse P. Gurses, Ph.D.; and IEA Awards Chariman, Andrew S. Imada, Ph.D. CPE
December 05, 2014
A team of nine researchers has won the 2014 International Ergonomics Association (IEA) Liberty Mutual Medal. The researchers received the honor for their scientific paper, “Technologies in the wild (TiW): human factors implications for patient safety in the cardiovascular operating room” (Ergonomics, Vol. 56, No. 2, pp. 205-219, 2013). The winning paper describes technology-induced 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 discusses the possible impact of these hazards on clinician cognition and performance based on observations at five large cardiac surgery centers in the USA.
The most prestigious award of its kind in the field of occupational ergonomics and safety, the IEA/Liberty Mutual Medal is awarded to the author of an original scientific paper that meets criteria for innovation and impact. Presented annually, the award recognizes outstanding original research leading to the reduction of work-related injuries and/or to the advancement of theory, understanding, and development of occupational safety research. An international review committee, established by the IEA, selects the winning contribution from among the applicants worldwide. The Medal carries a stipend of $10,000. The winners of the 2014 award will receive the Medal at the annual meeting of the Human Factors and Ergonomics Society, held from October 27–31 in Chicago, IL.
The winning paper provides a rich understanding of the risks to patient safety introduced by a multitude of technologies in a complex health care work system, specifically a cardiovascular operating room. For the investigation, researchers analyzed data collected during two 2.5 day visits to five sites. The data included observations from 20 cardiac surgeries (160 hours), follow-up surveys, and photographs of physical layouts and technologies.
Researchers found that the interaction of poorly designed technologies and physical spaces, organizational constraints and functional limitations has the potential to multiply latent risks in the use of cardiovascular operating room technologies. Specifically, the data revealed four types of technology-related hazards:
- Hazards due to technology design (e.g., user interface not providing at-a-glance view of critical information).
- Organizational factors (e.g., considerably outdated heart-lung equipment (for cardiac bypass) being used due to financial constraints).
- Physical/environmental factors (e.g., surgical suction canisters – important to check for blood loss during certain types of procedures- that are located behind the electrical arm and not visible to anesthesia).
- Ambiguity around the functional status of a particular technology (i.e., functioning or non-functioning).
The researchers also identified 21 types of cognitive processes (e.g., reduced attention, reduced vigilance, high workload, etc.) that can significantly impair performance. The processes when combined with technology-related hazards can increase the possibility of human errors and lead to adverse consequences.
The 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; George R. Kim, MD, FAAP of the Johns Hopkins University Schools of Medicine and Nursing; Jill A. Marsteller, PhD, MPP of the Johns Hopkins University Schools of Medicine and the Bloomberg School of Public Health, and Ayse P. Gurses, PhD, Peter J. Pronovost, MD, PhD, FCCM , and Lisa H. Lubomski, PhD, all of the Johns Hopkins University School of Medicine.
“My co-authors and I are thankful to Liberty Mutual and to Dr. Roger Haslam, Editor of Ergonomics for this honor. The Medal is recognition that human factors engineers can collaboratively work with healthcare experts to bring completely different, yet unique and rich perspectives to the same problem. As our healthcare system evolves in complexity and scope, a truly multidisciplinary effort will best address the challenges that still remain,” says Dr. Pennathur.
To access the study online, please visit www.tandfonline.com. About Liberty Mutual Research Institute for SafetyOwned and operated by Liberty Mutual Insurance, the Liberty Mutual Research Institute for Safety is an internationally recognized safety and health research facility. Through laboratory and field-based investigations, the Research Institute seeks to advance scientific knowledge in critical fields of study for the purpose of reducing injuries 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
Liberty Mutual Insurance helps preserve and protect the things people earn and own and build and cherish. Keeping this promise means we are there when our policyholders throughout the world need us most.
In business since 1912, and headquartered in Boston, Mass., today Liberty Mutual is a diversified insurer with operations in 30 countries around the world. The company is the third largest property and casualty insurer in the U.S. based on 2013 direct premium written as reported by the National Association of Insurance Commissioners.
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About International Ergonomics Association
The International Ergonomics Association (IEA) is the federation of ergonomics and human factors societies from around the world. The mission of the IEA is to elaborate and advance ergonomics science and practice, and to improve the quality of life by expanding its scope of application and contribution to society. For more information on the IEA, please visit www.iea.cc .
Contact: jo-ellen.mccarrick@libertymutual.com
