Presentation
Beyond the Checklist: A Human Factors Safety Analysis of Time-Out Processes
SessionPoster Session 2
DescriptionOverview of Topic & Background:
This project examines the application of Human Factors Safety Methods, specifically the Systems Engineering Initiative for Patient Safety (SEIPS) framework in conjunction with Contextual Inquiry, to analyze and improve organization-wide Time-Out processes in a multi-hospital system. Time-Outs are a necessary safety step, particularly before surgeries or invasive procedures, where care teams pause to verify patient identity and procedural details prior to procedure start. This critical pause in the procedure process was adapted from aviation safety and intended to prevent wrong site surgeries and medical errors in patient care.
Modern healthcare is a highly socio-technical system which presents many complexities and nuances, where traditional analysis methods often fall short. Although wrong site surgeries are considered never events, they are the 2nd most common preventable medical error, according to the Joint Commission (2024). Their low frequency of occurrence makes retrospective data insufficient for driving meaningful change, necessitating more robust, proactive approaches.
This study applies contextual inquiry and the SEIPS methodology to assess Time-Outs. Time-Outs can be viewed through two key lenses, compliance and quality. While compliance is relatively easy to measure, evaluating the quality of Time-Outs requires tools that account for human behavior, organizational culture, and environmental factors. The SEIPS methodology is not only one of the few tools specifically designed for patient safety, it offers a holistic view of the system, people, tools, tasks, and contexts, enabling deeper insights into latent vulnerabilities. This work highlights the power of proactive systems analysis to improve safety culture and reduce preventable harm, shifting Time-Outs from a procedural formality to a significant and valuable tool for patient safety.
As with most preventable medical errors, it’s typically the accumulation of small, innocuous failures that add up and result in a patient safety event. Human Factors Engineering provides the tools to identify these hidden, often overlooked risks and redesign processes for greater safety and resilience.
This study aimed to:
- Improve patient safety by enhancing the quality & compliance of Time-Out processes
- Accurately assess the current state of Time-Outs across diverse clinical settings through Contextual Inquiry
- Apply the SEIPS framework (PETT Scan/People Maps) to uncover systemic issues and generate actionable solutions within a complex healthcare environment
Application:
Time-Outs were analyzed across four distinct settings: Operating Rooms (OR), Non-OR with Sedation, Non-OR without Sedation, and Inpatient/Bedside procedures. Using Contextual Inquiry, including on-site observations and semi-structured interviews, the study captured the Work-As-Imagined (WAI) in comparison to Work-As-Done (WAD) to reveal real-world system dynamics. Barriers and facilitators were identified and categorized using the SEIPS PETT Scan tool. In addition to the PETT Scan, SEIPS People Maps were utilized to visualize the people and interactions in each of the 4 work system settings as well as display their observed level of engagement in the Time-Out processes. Additionally, a set of Future State People Maps created the foundation for ideal state implementations. This approach yielded over 120 insights, offering a rich understanding of the human, environmental, and organizational factors influencing Time-Out execution. Findings were subsequently shared with Leadership and Executive Committees using the SEIPS model as the organizing framework, enabling clearer communication of system complexity/interactions and supporting more effective change management.
Takeaways:
- A Human Factors approach, combining Contextual Inquiry and SEIPS 101 tools, can effectively and comprehensively analyze a high risk, routine clinical process across a large healthcare system.
- Applying Human Factors tools within real-world healthcare settings reveals the nuanced interplay between people, processes, technologies, and environments.
- Using the SEIPS Model not only as an analytic framework but also as a structure for communicating findings can strengthen safety culture and support meaningful change management.
Sources:
The Joint Commission. (2024). The Joint Commission Sentinel Event Data 2024 Annual Review. In https://www.jointcommission.org/en-us/knowledge-library/sentinel-events. https://digitalassets.jointcommission.org/api/public/content/eac7511986c0442a9c1ae04b1aa02cc0?v=ad34daa0&_gl=1*1tkvdk9*_gcl_au*MTY5NTUxNjg5NC4xNzU1NzgzNzMz*_ga*NDg0MDk2NTg2LjE3NDY2MzAzODUu*_ga_K31T0BHP4T*czE3NTgzMzkyNDckbzUkZzEkdDE3NTgzMzkzMzUkajM3JGwwJGgw
This project examines the application of Human Factors Safety Methods, specifically the Systems Engineering Initiative for Patient Safety (SEIPS) framework in conjunction with Contextual Inquiry, to analyze and improve organization-wide Time-Out processes in a multi-hospital system. Time-Outs are a necessary safety step, particularly before surgeries or invasive procedures, where care teams pause to verify patient identity and procedural details prior to procedure start. This critical pause in the procedure process was adapted from aviation safety and intended to prevent wrong site surgeries and medical errors in patient care.
Modern healthcare is a highly socio-technical system which presents many complexities and nuances, where traditional analysis methods often fall short. Although wrong site surgeries are considered never events, they are the 2nd most common preventable medical error, according to the Joint Commission (2024). Their low frequency of occurrence makes retrospective data insufficient for driving meaningful change, necessitating more robust, proactive approaches.
This study applies contextual inquiry and the SEIPS methodology to assess Time-Outs. Time-Outs can be viewed through two key lenses, compliance and quality. While compliance is relatively easy to measure, evaluating the quality of Time-Outs requires tools that account for human behavior, organizational culture, and environmental factors. The SEIPS methodology is not only one of the few tools specifically designed for patient safety, it offers a holistic view of the system, people, tools, tasks, and contexts, enabling deeper insights into latent vulnerabilities. This work highlights the power of proactive systems analysis to improve safety culture and reduce preventable harm, shifting Time-Outs from a procedural formality to a significant and valuable tool for patient safety.
As with most preventable medical errors, it’s typically the accumulation of small, innocuous failures that add up and result in a patient safety event. Human Factors Engineering provides the tools to identify these hidden, often overlooked risks and redesign processes for greater safety and resilience.
This study aimed to:
- Improve patient safety by enhancing the quality & compliance of Time-Out processes
- Accurately assess the current state of Time-Outs across diverse clinical settings through Contextual Inquiry
- Apply the SEIPS framework (PETT Scan/People Maps) to uncover systemic issues and generate actionable solutions within a complex healthcare environment
Application:
Time-Outs were analyzed across four distinct settings: Operating Rooms (OR), Non-OR with Sedation, Non-OR without Sedation, and Inpatient/Bedside procedures. Using Contextual Inquiry, including on-site observations and semi-structured interviews, the study captured the Work-As-Imagined (WAI) in comparison to Work-As-Done (WAD) to reveal real-world system dynamics. Barriers and facilitators were identified and categorized using the SEIPS PETT Scan tool. In addition to the PETT Scan, SEIPS People Maps were utilized to visualize the people and interactions in each of the 4 work system settings as well as display their observed level of engagement in the Time-Out processes. Additionally, a set of Future State People Maps created the foundation for ideal state implementations. This approach yielded over 120 insights, offering a rich understanding of the human, environmental, and organizational factors influencing Time-Out execution. Findings were subsequently shared with Leadership and Executive Committees using the SEIPS model as the organizing framework, enabling clearer communication of system complexity/interactions and supporting more effective change management.
Takeaways:
- A Human Factors approach, combining Contextual Inquiry and SEIPS 101 tools, can effectively and comprehensively analyze a high risk, routine clinical process across a large healthcare system.
- Applying Human Factors tools within real-world healthcare settings reveals the nuanced interplay between people, processes, technologies, and environments.
- Using the SEIPS Model not only as an analytic framework but also as a structure for communicating findings can strengthen safety culture and support meaningful change management.
Sources:
The Joint Commission. (2024). The Joint Commission Sentinel Event Data 2024 Annual Review. In https://www.jointcommission.org/en-us/knowledge-library/sentinel-events. https://digitalassets.jointcommission.org/api/public/content/eac7511986c0442a9c1ae04b1aa02cc0?v=ad34daa0&_gl=1*1tkvdk9*_gcl_au*MTY5NTUxNjg5NC4xNzU1NzgzNzMz*_ga*NDg0MDk2NTg2LjE3NDY2MzAzODUu*_ga_K31T0BHP4T*czE3NTgzMzkyNDckbzUkZzEkdDE3NTgzMzkzMzUkajM3JGwwJGgw
Event Type
Poster Presentation
TimeTuesday, March 244:45pm - 6:15pm EDT
LocationRhinelander Gallery
Hospital Environments