Presentation
PS3 - Application of Broken Windows Theory to Identify Flow Disruptions in Neurosurgery Procedure
DescriptionBackground:
Addressing flow disruptions in neurosurgery requires a multifaceted approach. Strategies such as improved communication protocols, minimizing interruptions, improving coordination among team, optimizing operating-room layout, and promoting user-centered design can help mitigate the challenges and enhance the overall flow and safety of neurosurgical procedures. By identifying and addressing these issues, healthcare professionals can work towards ensuring optimal patient care and better outcomes in neurosurgery.
Methods:
30 neurosurgery cases were observed at two tertiary care facilities. The data collected were from wheels into the operating room to wheels out from the operating room. Data points were categorized using a human factors taxonomy known as RIPCHORD-TWA (Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis), which aims to enhance patient care by emphasizing the importance of human-centered operating room design and threat window analysis.
Results:
Of the 541 total disruptions observed, coordination issues were the most prevalent (26.25%), followed by layout issues (26.06%), issues related to interruption (22.55%), communication (22.37%), equipment issues (2.40%) and usability issues (0.37%) comprised the remainder of the observations. This translated into one disruption per every 2.7 minutes over the course of the 30 surgeries. Disruptions involving coordination and layout issues were more prevalent during neurosurgical operation.
Conclusions:
Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows to analyze potential threats to the integrity of the care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.
The subsequent phase of this study will involve staggered implementation of specific interventions. Analyzing the ensuing data will provide a new benchmark for comparison against baseline/pre-intervention data, gauging the effectiveness of these interventions. Outcome measures like reduced medical errors, adverse events, and mortality rates will further validate the efficacy of these targeted interventions. Ultimately, this approach may offer a more enduring and successful strategy for mitigating threats to the delivery of care for traumatic injuries.
Addressing flow disruptions in neurosurgery requires a multifaceted approach. Strategies such as improved communication protocols, minimizing interruptions, improving coordination among team, optimizing operating-room layout, and promoting user-centered design can help mitigate the challenges and enhance the overall flow and safety of neurosurgical procedures. By identifying and addressing these issues, healthcare professionals can work towards ensuring optimal patient care and better outcomes in neurosurgery.
Methods:
30 neurosurgery cases were observed at two tertiary care facilities. The data collected were from wheels into the operating room to wheels out from the operating room. Data points were categorized using a human factors taxonomy known as RIPCHORD-TWA (Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis), which aims to enhance patient care by emphasizing the importance of human-centered operating room design and threat window analysis.
Results:
Of the 541 total disruptions observed, coordination issues were the most prevalent (26.25%), followed by layout issues (26.06%), issues related to interruption (22.55%), communication (22.37%), equipment issues (2.40%) and usability issues (0.37%) comprised the remainder of the observations. This translated into one disruption per every 2.7 minutes over the course of the 30 surgeries. Disruptions involving coordination and layout issues were more prevalent during neurosurgical operation.
Conclusions:
Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows to analyze potential threats to the integrity of the care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.
The subsequent phase of this study will involve staggered implementation of specific interventions. Analyzing the ensuing data will provide a new benchmark for comparison against baseline/pre-intervention data, gauging the effectiveness of these interventions. Outcome measures like reduced medical errors, adverse events, and mortality rates will further validate the efficacy of these targeted interventions. Ultimately, this approach may offer a more enduring and successful strategy for mitigating threats to the delivery of care for traumatic injuries.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives