Case Study: Surgical Room Efficiency
Objective
Hospital Asks:
How can the surgical room be improved to avoid costly errors?
Provide recommendations for the hospital decision makers regarding: foreign body retention, loss of pathological tissues, surgical site errors.
My Role
Industry consultant with a psychology and human factors lens
Invited to be part of a team with industry and academic practitioners from various fields including Human Factors, Ergonomics, IT, and Information Management.
Key Research Questions
How to improve and avoid medical errors regarding: foreign body retention, loss of pathological tissues, and surgical site errors?
Are there any UI/UX, processes, ergonomic, or behavioural changes that can be made to improve operation room efficiency and avoid medical errors?
What other recommendations?
Due to confidentiality, below is an overall general workflow and my role.
Research:
Picture taken from http://www.chimei.org.tw/asp/79070/addfile/573.pdf
Background (Primary) Research
An in-depth analysis and background research was conducted already by other members of the team. A snippet of own background research before hospital visit:
In U.S., medical errors are costly, up to $29 billion (USD) yearly
Taiwan implemented a national wide reporting system (Taiwan Patient-safety Reporting system, TPR) in 2003, to encourage incident reporting to improve patient safety and also to encourage reporting of medical incidents anomalously.
https://www.patientsafety.mohw.gov.tw/Content/Messagess/Contents.aspx?SiteID=2&MmmID=621316242156723353
A hesitancy in nurses in Taiwan to report incidents
https://www.sciencedirect.com/science/article/abs/pii/S0029655409000864
A high likelihood of high burnout for medical staff
https://journals.sagepub.com/doi/full/10.1177/0046958016679306
Understanding the Patient and Medical Professionals Journey via Review of Documentations
Videos
Clinical Documentations including standard operating procedure (SOP)
Case Studies
2. Qualitative Methods
Ethnography Observation in Operation Rooms
Shadowing
Group Interview with Key Influencers
Key Influencers
The hospital had 30 medical personnel with key influencers including directors of different key departments to meet with the human factors group.
Qualitative method include on-set observations of Surgical Sponge Procedures:
Reliance on manual counting
https://lighthouse.mq.edu.au/article/april-2020/What-happens-when-surgical-tools-are-left-inside-a-patient
3. Qualitative and Quantitative Results
Photo by Jozemara Friorili Lemes from Pexels
Video-Analysis of Behaviour
I conducted a video-analysis of personnel in the surgical room to illustrate inefficiencies in the surgical room. My goal was to show how video-analysis of behaviour on a macro-level can be used as a tool to illustrate interesting human behaviour.
4. Presentation to Key Decision Makers
Human factors recommendations included environment, equipment, movement, system, and cognition. My presentation was focused on a cognitive-behavioural approach, attending to human behaviour on a macro system level.
5. Follow-Up Meeting and Future Impact
After review of recommendations, hospital followed-up with which changes they are interested in implementing
The team will continue to work closely with the hospital