Pennathur Is Lead Author on Research Team Receiving 2014 Liberty Mutual Award

Friday, April 18, 2014

Priyadarshini R. Pennathur, assistant professor of mechanical and industrial engineering, is the lead author a member of a team of nine researchers who received the 2014 Liberty Mutual Award for their scientific paper, “Technologies in the wild (TiW): human factors implications for patient safety in the cardiovascular operating room.” 

The paper, published in Ergonomics (Vol. 56, No. 2, pp. 205-219, 2013), provides a richer and more realistic understanding of the potential risks to patient safety introduced by a multitude of technologies in a complex health care work system, specifically a cardiovascular operating room.

The award was presented at the 2014 Annual Conference of the Institute of Ergonomics and Human Factors held in April at Grand Harbour Hotel in Southampton, UK.

The Best Paper Award promotes excellence in safety and health research.  The annual award, established in 2005 by the Liberty Mutual Research Institute for Safety and the UK Institute for Ergonomics and Human Factors (formerly the Ergonomics Society), recognizes the paper that best contributes to the advancement of ergonomics.  The editors of Ergonomics, in conjunction with the Institute’s Honors Committee, select the winner from all of the papers published in the journal over the given year.

The winning paper describes technology-related hazards, that is, technologies that could lead to a medical error, in a complex, fast-paced, and high-stakes work environment – the cardiovascular operating room. The paper also examines the possible impact of these hazards on clinician cognition and performance based on an observational study on five large cardiac surgery centers in the USA. 

For the investigation, researchers conducted an in-depth data analysis of technology-related hazards.   This prospective study applied multiple methods aimed at identifying risks to patient safety in cardiovascular operating rooms.  The researchers focused specifically on technology-related hazards/risks.  The resulting data were collected during two 2.5 day visits to five sites, and included observational data from 20 cardiac surgeries (160 hours), follow-up questions to clarify and obtain more detailed information on the observations, and photographing of physical layouts and technologies for detailed analysis by human factors experts.

The data revealed four types of technology-related hazards:

  1. Hazards due to technology design (e.g., user interface not providing at-a-glance view of critical information).
  2. Organizational factors (e.g., considerably out-dated heart-lung equipment (for cardiac  bypass) being used due to financial constraints).
  3. Physical/environmental factors (e.g., surgical suction canisters – important to check for blood loss during certain types of procedures- are always behind the electrical arm and not visible to anesthesia).
  4. Functional status of a particular technology (i.e., functioning or non-functioning).

The researchers also identified 21 types of negatively affected cognitive processes (e.g., reduced attention, reduced vigilance, high workload, etc.).  The processes when combined with technology-related hazards may potentially reduce human performance and increase the possibility of human errors.

The paper suggests that manufacturers should design safety features into technologies instead of transferring the burden of troubleshooting technologies to the health care providers.