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Radiography as a sociotechnical system-Improving patient identification with a multi-level human factors approach

Published version
Peer-reviewed

Type

Article

Change log

Authors

Woodward, Matthew 
Nayak, Rounaq 
McCulloch, Peter 

Abstract

Irradiation of the wrong patient or wrong site is a reportable adverse event for hospitals. Improvement efforts to date have been narrowly targeted, often without consideration of wider contextual factors. This study applied a systems human factors/ergonomics (HFE) approach in an NHS trust to develop interventions across micro, unit and organisation levels. At the micro level, the workspace was adapted to reduce distractions during safety critical work. At the unit level a standard operating procedure for patient identification was designed with staff alongside the introduction of wristband barcode scanners. At the organisation level safety workshops were run for staff in the radiology directorate. These introduced a systems approach to managing risk, encouraged near miss reporting and employed scenario-based exercises to raise discussion of risk-efficiency trade-offs. Following implementation interruptions in the control rooms decreased by 34% (from a mean of 4.91/10 minutes). Interrupted time series analysis showed that the interventions were associated with a decrease in patient identification incidents (rate ratio = 0.37), and an increase in near miss reporting (rate ratio = 2.5), representing an additional 4.7 reports/month. The workshops raised a wide range of system components that influenced the imaging task and provided examples of situated and structural resilience attributes. The safe provision of imaging across different modalities and physical locations is a challenge for many radiology departments; this study indicates that a multi-level systems approach can reduce risk.

Description

Keywords

Radiography, Human factors, Ergonomics, Distractions, FMEA, Patient identification, Resilience, Healthcare

Journal Title

SAFETY SCIENCE

Conference Name

Journal ISSN

0925-7535
1879-1042

Volume Title

Publisher

Elsevier BV
Sponsorship
Health Education England