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Proceedings of the 2012 Symposium on Human Factors and Ergonomics in Health Care: Bridging the Gap

INTRODUCTION 

Anthony D. Andre, Symposium Organizer and Chair
 

The inaugural HFES 2012 Symposium on Human Factors and Ergonomics in Health Care brought together an extraordinary mix of researchers, academicians, practitioners, health care providers, regulators, and medical device and pharmaceutical companies¾all gathered to share a common experience rooted in the science and application of human factors/ergonomics in health care.
 

Over the course of three days in March 2012, a well-crafted combination of science, experiences, guidelines, principles, and best practices was exchanged among 450 attendees who are at the forefront of patient and health-care provider safety. The information exchange took place in the context of three program tracks: Patient and Health-Care Provider Safety, Health-Care Information Technology, and Medical Device Design. I'm grateful to the track committee chairs and members for crafting a superb symposium program, which is represented in part by the papers in this proceedings.
 

These papers, along with the 150+ oral and poster presentations, represent the state oftheart in human factors/ergonomics theory and application toward improving the safety, effectiveness, and usability of health-care systems and environments.


The papers are freely available; simply click the linked title(s) of interest. Copyright 2012 by Human Factors and Ergonomics Society. All rights reserved. Contents may not be reused without permission of HFES (contact Lois Smith at lois@hfes.org, 310/394-1811).

CONTENTS

Patient and Health-Care Provider Safety Track


1
Analysis and Mitigation of Reported Informatics Patient Safety Adverse Events at the Veterans Health Administration
Lesley Taylor, Scott D. Wood, and Roger J. Chapman


8
An Evaluation of a Low Dose Rate (LDR) Brachytherapy Procedure Using a "Systems Engineering & Error Analysis Methodology for Health Care" (SEABH)
Liam Chadwick, Enda F. Fallon, and Wil. J. van der Putten


14
Emergency Medical Responders and Physicians: Diagnostics, Decision Making and Medical Management in High Stakes Situations
Moin Rahman


20
Human Factors and Lean in the ER: A Review of the Literature
Laura Moody


27
Analysis of Hospital Oncology Department Pharmacy Operations
Esa Rantanen, Joe Deeter, Sean Burke, and Yao Wang


35
Mitigating Risks Associated With Administering Multiple Intravenous Infusions: Methods for Organizing and Analyzing Proactive Risk Data
Andrea Cassano-Piché, Mark Fan, and Anthony C. Easty


39
The Effect of Affect: Decision Making in the Emotional Context of Health Care
Marc L. Resnick


45
Human Reliability Analysis in Healthcare
Joe Deeter and Esa Rantanen


52
Improving Ambulatory Chemotherapy Safety: Results and Impact of a Multi-Disciplinary, Multi-Jurisdictional Proactive Risk Study
Andrea Cassano-Piché, Rachel White, Jennifer Jeon, and Anthony C. Easty


60
Addressing Risk Factors in Morphine Administration: A Collaborative Prototyping Approach
Catherine Campbell, Avi Parush, Thomas Garvey, Jacqueline Ellis, Régis Vaillancourt, and Daniel Lebreux


68
Overcoming Barriers in Healthcare: Strategies for Resilience in Coordination of Follow-Up for Cancer Diagnosis
Michael W. Smith, Traber Giardina, and Hardeep Singh


73
Human Factors Evaluation of an Interventional Trauma Operating Room Mock-Up
Susan Biesbroek, Jonas Shultz, Andrew Kirkpatrick, and John Kortbeek


79
The Other 21st Century Healthcare Issue: An Ergonomic Approach to Addressing Workplace Injuries
Marnie Myhre


83
The Role of Knowledge, Control Beliefs, and Surface Types on the Risk Judgments of Environmental Service Workers
Michelle R. Bryant, Anne Collins McLaughlin, and Fran Walsh


87
Cataloging Errors From Reported Informatics Patient Safety Adverse Events
Roger J. Chapman, Lesley Taylor, and Scott D. Wood


95
Human Factors Review of EMS Ground Ambulance Design
Susan Biesbroek and Elise Teteris


102
Standardized Color-Coding Solution Labeling in the Operating Room
Linda Cicconi, David Eibling, and Michael Mangione


105
Leveraging Community Health Workers in Low Resource Health Delivery Systems
Paulina Cano, Natalia Espino, Jacqueline Loweree, Monica Cadena, Arunkumar Pennathur, Luis R. Contreras-Sapien, Rebecca Ramos, and Rosalba Ruiz
 

Health Care Information Technology Track


112
Cognitive Interaction Analysis of Clinical Encounters
Wayne Zachary and Russell Maulitz


120
Situation Awareness-Oriented Design (SAOD) and the CDC Biophusion Center
Taylor J. Anderson and Cheryl A. Bolstad


127
Activity Cycles and Information Alignment in Healthcare Information Flow
Marissa A. Vallette and Barrett S. Caldwell


131
Mining MAUDE: Human Factors Perspectives on EHR and Device Design From the FDA Manufacturers and Users Device Experience Database
Steven D. Harris and Robert A. North


138
Designing Health Care IT for Interruption-Filled Environments: Redesigning Interface Elements of a Chemotherapy Medication System
Varuna Prakash and Patricia Trbovich


145
Re-Engineering the Healthcare Team: Meeting the Needs of Providers With Information Specialists
Ruthann Lipman, David Eibling, Robert Budacki, Shannon Gdaniec, and Sidney Lipman


151
VOOGLE: A Query-Based Visualization Application to Support Clinician Cognition During EHR Access
David Eibling and Augie Turano


157
Correlating Data From Different Sensors to Increase the Positive Predictive Value of Alarms: An Empiric Assessment
Yuval Bitan and Michael F. O'Connor


159
Development of an Electronic Patient Record Selection Instrument
Marc L. Resnick


165
Engineering Better Health IT: Cognitive Systems Engineering of a Novel Emergency Department IT System
Theresa K. Guarrera, Robert J. Stephens, Lindsey N. Clark, Nicolette M. McGeorge, Rollin J. (Terry) Fairbanks, Shawna J. Perry, Robert Wears, Li Lin, and Ann M. Bisantz


166
User-Centered Design: Clothing The EMR Emperor
M. Schaeffer and B. J. Moore


173
UWoN (User Workflow Notation): A Visualization Tool for User Workflow Analysis and Modeling for Developing Healthcare IT
Xianjun Sam Zheng, Stefan Christov, Yu Sun, and Xiping Song


179
Safety in Managing Patient Test Data: Assessing Perceptions, Attitudes, and Actions
Jennifer Cloud-Buckner and Jennie J. Gallimore

 

Medical Device Design Track


187
A Multidisciplinary Human-Centered Approach to the Design of Incubation Systems
Thomas Ferris and Mardelle Shepley


192
Development of a Medical Support Garment for a Patient With Giant Omphalocele: A Case Study
Adriana Petrova and Semra Peksoz


197
Use of a Surgeon as a Validation Instrument in a High-Fidelity Simulation Environment
Ben Andrack, Trevor Byrnes, Luis E. Bernal Vera, Gerold Bausch, and Werner Korb


202
Semantic Profiling: A Method for Relating Auditory Device Signals to Medical Messages
James A. Kleiss, Emil M. Georgiev, and Scott W. Robinson


208
Survey of Anthropometric Data Collection Methods of Indian Population for Design of Proportional Medical Devices
Meera Ramachandran and Sashidharan Komandur


212
QOC-E: A Mediating Representation to Support the Development of Shared Rationale and Integration of Human Factors Advice
Chris Vincent, Ann Blandford, and Yunqui Li


219
Situated Interactions of Lay Users With Home Hemodialysis Technology: Influence of Broader Context of Use
Atish Rajkomar, Ann Blandford, and Astrid Mayer


224
Work Domain Analysis for Designing a Radiotherapy System Control Interface
Chun Wu, Jennifer Jeon, Joseph A. Cafazzo, and Catherine M. Burns

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