Radiography as a sociotechnical system-Improving patient identification with a multi-level human factors approach
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Authors
Woodward, Matthew
Nayak, Rounaq
McCulloch, Peter
Publication Date
2022Journal Title
SAFETY SCIENCE
ISSN
0925-7535
Publisher
Elsevier BV
Type
Article
This Version
VoR
Metadata
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Woodward, M., Nayak, R., & McCulloch, P. (2022). Radiography as a sociotechnical system-Improving patient identification with a multi-level human factors approach. SAFETY SCIENCE https://doi.org/10.1016/j.ssci.2022.105679
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.
Keywords
radiography, human factors, systems ergonomics, healthcare, patient identification, resilience
Sponsorship
Health Education England
Identifiers
External DOI: https://doi.org/10.1016/j.ssci.2022.105679
This record's URL: https://www.repository.cam.ac.uk/handle/1810/334168
Rights
Attribution-NonCommercial-NoDerivatives 4.0 International
Licence URL: https://creativecommons.org/licenses/by-nc-nd/4.0/
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