Human Factors Analysis of Latent Safety Threats in a Pediatric Critical Care Unit*

Abstract

To identify unique latent safety threats spanning routine pediatric critical care activities and categorize them according to their underlying work system factors (i.e., "environment, organization, person, task, tools/technology") and associated clinician behavior (i.e., "legal": expected compliance with or "illegal-normal": deviation from and "illegal-illegal": disregard for standard policies and protocols). DESIGN:A prospective observational study with contextual inquiry of clinical activities over a 5-month period. SETTING: Two PICUs (i.e., medical-surgical ICU and cardiac ICU) in an urban free-standing quaternary children's hospital. SUBJECTS:Attending physicians and trainees, nurse practitioners, registered nurses, respiratory therapists, dieticians, pharmacists, and patient services assistants were observed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Conducted 188 hours of observations to prospectively identify unique latent safety threats. Qualitative observational notes were analyzed by human factors experts using a modified framework analysis methodology to summarize latent safety threats and categorize them based on associated clinical activity, predominant work system factor, and clinician behavior. Two hundred twenty-six unique latent safety threats were observed. The latent safety threats were categorized into 13 clinical activities and attributed to work system factors as follows: "organization" (n = 83; 37%), "task" (n = 52; 23%), "tools/technology" (n = 40; 18%), "person" (n = 32; 14%), and "environment" (n = 19; 8%). Twenty-three percent of latent safety threats were identified when staff complied with policies and protocols (i.e., "legal" behavior) and 77% when staff deviated from policies and protocols (i.e., "illegal-normal" behavior). There was no "illegal-illegal" behavior observed. CONCLUSIONS:Latent safety threats span various pediatric critical care activities and are attributable to many underlying work system factors. Latent safety threats are present both when staff comply with and deviate from policies and protocols, suggesting that simply reinforcing compliance with existing policies and protocols, the common default intervention imposed by healthcare organizations, will be insufficient to mitigate safety threats. Rather, interventions must be designed to address the underlying work system threats. This human factors informed framework analysis of observational data is a useful approach to identifying and understanding latent safety threats and can be used in other clinical work systems.

Video-Recorded In Situ Simulation Before Moving to the New Combined Neonatal/Pediatric Intensive Care Facility: An Observational Study

“…In the current study, we have used high-fidelity simulations in the new environment before moving to a new ICU to identify possible issues in order to address them before endangering real patients. With this approach, we are one step ahead and focus on another topic when compared with others who have tried to identify threats to patient safety through observations of medical activities in real pediatric patients (28).…”

Editor’s Choice Articles for March

“…Trbovich PL, Tomasi JN, Kolodzey L, et al: Human Factors Analysis of Latent Safety Threats in a Pediatric Critical Care Unit (1).…”

Latent Safety Threats in the PICU: Finding the Unseen*

“…To be purposefully redundant, Trbovich et al (14) add to the existing literature showing our current systems for capturing adverse events is insufficient; what we don't see can hurt our patients. The identification and classification of LSTs provide a framework to proactively address systemic issues before they result in adverse events for critically ill children.…”

“…The authors reference a complimentary study using their findings to identify actionable items that require minimal effort. The current study by Trbovich et al (14) addresses the analysis aspect of a quality improvement cycle. In the framework of HF and quality improvement research, next steps should include designing and implementing an intervention and evaluating its impact on patient outcomes.…”

“…The investigators present extraordinary detail about 226 LSTs and readers should spend time with the Supplement (14). Reiterating their major findings, LSTs were categorized into work system factors: 36.7% organization; 23.0% task; 17.7% tools/technology; 14.2% person; and 8.4% physical environment.…”