Identifying Hazards in the Cardiac Operating Room* Event-driven, - PowerPoint PPT Presentation

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Identifying Hazards in the Cardiac Operating Room* Event-driven, nonlinear, unpredictable systems Team-based, high workload, interruptions TECHNOLOGIES in THE WILD! * 1 * Gurses et al., 2012 BMJ Q&S; Pennathur et al.,

Identifying Hazards in the Cardiac Operating Room* • Event-driven, nonlinear, unpredictable systems • Team-based, high workload, interruptions • TECHNOLOGIES in THE WILD! * 1 * Gurses et al., 2012 BMJ Q&S; Pennathur et al., Ergonomics, 2013
SEIPS Model of Work System and Patient Safety 2 Carayon et al . BMJ Q&S, 2006
Systems Ambiguity* • Task ambiguity • Responsibility ambiguity • Expectation ambiguity • Method ambiguity • Exception ambiguity * Gurses et al. (2008) Systems ambiguity and guideline compliance, BMJ Quality and Safety , 17:351-359 3
Nurse Coordinator’s Clipboard Whitening out non-essential items Cutting out unnecessary parts Taping print-outs of two adjacent units Transferring information from the old clipboard 4 Gurses et al. J Biomed Inform 2009; 42(4): 667-677.

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