Abstract
Patient safety remains a significant concern even in light of some improvements, such as reduction of healthcare-associated complications for hospitalized patients. We argue that renewed attention for systems approaches is necessary in order to more effectively tackle complex patient safety problems. We propose the concept of patient journey as a new perspective for patient safety. The spatio-temporal interactions and care transitions are the essence of the patient journey. The patient journey perspective emphasizes patients’ interactions with multiple care settings over time.
We review different process modeling approaches aimed at describing the patient journey. This includes methods based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. Examples described in this chapter include modeling of the medication management process and modeling of care coordination for elderly patients with chronic conditions. The examples show how human factors and systems engineering can contribute to analyzing processes in the patient journey and, therefore, provide opportunities for addressing patient safety in a systematic manner.
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References
Abramson EL, Bates DW, Jenter C, Volk LA, Barron Y, Quaresimo J et al (2012) Ambulatory prescribing errors among community-based providers in two states. J Am Med Inform Assoc 19(4):644–648
Agency for Healthcare Research and Quality (2015) 2014 National Healthcare Quality & disparities report. Agency for Healthcare Research and Quality, Rockville. Contract No.: AHRQ Pub. No. 15-0007
AHRQ (2014) National healthcare quality and disparities report. Agency for Healthcare Research and Quality, Rockville, p 2015
Alyousef B, Carayon P, Hoonakker P, Hundt AS, Cartmill R, Tomcavage J, et al (2012) Care managers’ challenges in using multiple health IT applications. In: The Human Factors and Ergonomics Society (ed) Proceedings of the human factors and ergonomics society 56th annual meeting. The Human Factors and Ergonomics Society, Santa Monica, pp 1748–1752
Alyousef B, Carayon P, Hoonakker P, Hundt AS, Salek D, Tomcavage J (2017) Obstacles experienced by care managers in managing information for the care of chronically ill patients. Int J Human Comput Interact 33(4):313–321
Anderson G (2010) Chronic care: making the case for ongoing care. Robert Wood Johnson Foundation, Princeton
Bates DW, Leape LL, Petrycki S (1993) Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med 8(6):289–294
Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D et al (1995) Incidence of adverse drug events and potential adverse drug events: implications for prevention. J Am Med Assoc 274(1):29–34
Ben-Tovim DK, Dougherty ML, O’Connell TJ, McGrath KM (2008) Patient journeys: the process of clinical redesign. Med J Aust 188(6):S14–SS7
Berdot S, Gillaizeau F, Caruba T, Prognon P, Durieux P, Sabatier B (2013) Drug administration errors in hospital inpatients: a systematic review. PLoS One 8(6):e68856
Beuscart-Zéphir M-C, Pelayo S, Anceaux F, Maxwell D, Guerlinger S (2007) Cognitive analysis of physicians and nurses cooperation in the medication ordering and administration process. Int J Med Inf 76:S65–S77
Bodenheimer T (2008) Coordinating care—a perilous journey through the health care system. N Engl J Med 358(10):1064–1071
Brixey JJ, Tang Z, Robinson DJ, Johnson CW, Johnson TR, Turley JP et al (2008) Interruptions in a level one trauma center: a case study. Int J Med Inf 77(4):235–241
Calabrese AD, Erstad BL, Brandl K, Barletta JF, Kane SL, Sherman DS (2001) Medication administration errors in adult patients in the ICU. Intensive Care Med 27(10):1592–1598
Carayon P, Wood KE (2009) Patient safety: the role of human factors and systems engineering. In: Rouse WB, Cortese DA (eds) Engineering the system of healthcare delivery. IOS Press, Amsterdam, pp 23–46
Carayon P, Hundt AS, Karsh B-T, Gurses AP, Alvarado CJ, Smith M et al (2006) Work system design for patient safety: the SEIPS model. Qual Saf Health Care 15(Suppl I):i50–ii8
Carayon P, Alyousef B, Hoonakker PLT, Hundt AS, Cartmill R, Tomcavage J et al (2012) Challenges to care coordination posed by the use of multiple health IT applications. Work (Reading, Mass) 41(2):4468–4473
Carayon P, Karsh B-T, Gurses AP, Holden RJ, Hoonakker P, Hundt AS et al (2013) Macroergonomics in health care quality and patient safety. Rev Hum Factors Ergon 8:4–54
Carayon P, Wetterneck TB, Rivera-Rodriguez AJ, Hundt AS, Hoonakker P, Holden R et al (2014a) Human factors systems approach to healthcare quality and patient safety. Appl Ergon 45(1): 14–25
Carayon P, Wetterneck TB, Cartmill R, Blosky MA, Brown R, Kim R et al (2014b) Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. BMJ Qual Saf 23(1):56–75
Carayon P, Wetterneck TB, Alyousef B, Brown RL, Cartmill RS, McGuire K et al (2015a) Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit. Int J Med Inf 84(8):578–594
Carayon P, Ju F, Ri C, Hoonakker P, Wetterneck TB, Li J (2015b) Medication error propagation in intensive care units. Proc Human Factors Ergon Soc Annu Meeting 59(1):518–521
Carayon P, Ju F, Cartmill R, Hoonakker P, Wetterneck TB, Li J (2015c) Medication error propagation in intensive care units. In: The Human Factors and Ergonomics Society (ed) Proceedings of the human factors and ergonomics society annual meeting, 59. The Human Factors and Ergonomics Society, Santa Monica, pp 518–521
Carayon P, Hundt A, Hoonakker P, Kianfar S, Alyousef B, Salek D et al (2015d) Perceived impact of care managers’ work on patient and clinician outcomes. Eur J Person Centered Healthcare 3(2):158–167
Carayon P, Cartmill R, Hoonakker P, Hundt AS, Salek D, Walker J, Tomcavage J (2016) Collaborative processes of care managers in the detection and recovery of medication errors. In: Mollo V, Falzon P (eds) Proceedings of the healthcare systems ergonomics and patient safety conference, Toulouse, France, pp 87–92
Daniellou F, Rabardel P (2005) Activity-oriented approaches to ergonomics: some traditions and communities. Theor Issues Ergon Sci 6(5):353–357
Dean B, Schachter M, Vincent C, Barber N (2002) Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 359(9315):1373–1378
Dixon CA, Punguyire D, Mahabee-Gittens M, Ho M, Lindsell CJ (2015) Patient flow analysis in resource-limited settings: a practical tutorial and case study. Global Health Sci Pract 3(1): 126–134
Donabedian A (1988) The quality of care. How can it be assessed? J Am Med Assoc 260(12):1743–1748
Douglas S, Cartmill R, Brown R, Hoonakker P, Slagle J, Van Roy KS et al (2012) The work of adult and pediatric intensive care unit nurses. Nurs Res 62(1):50–58
Doyle C, Lennox L, Bell D (2013) A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 3(1):1–18
Eason K, Dent M, Waterson P, Tutt D, Hurd P, Thornett A (2012) Getting the benefit from electronic patient information that crosses organisational boundaries. Final report. NIHR Service Delivery and Organisation Programme, Department of Health, London
Gurses AP, Ozok AA, Pronovost PJ (2012) Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf 21(4):347–351
Hollenberg S, Heitner S (2012) Congestive heart failure. Cardiology in family practice: a practical guide. Humana Press, New York, pp 91–111
Hollnagel E (2015) Chapter 18: Why is work-as-imagined different from work-as-done? In: Wears RL, Hollnagel E, Braithwaite J (eds) Resilient health care, Volume 2: The resilience of everyday clinical work. Ashgate Publishing, Farnham
Holman GT, Beasley JW, Karsh BT, Stone JA, Smith PD, Wetterneck TB (2016) The myth of standardized workflow in primary care. J Am Med Inform Assoc 23(1):29–37
Hoonakker PLT, Carayon P, Alyousef B, Cartmill RS, Hundt AS, Kianfar S, et al (2014) Build it and they will come? Assessment of use, usability, and usefulness of the Keystone Health Information Exchange. In: Organizational design and management (ODAM) conference; 2014 Aug 17-20. IEA Press, Copenhagen
Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century. National Academy Press, Washington, DC
International Ergonomics Association (IEA) (2018) Defintiion and domains of ergonomics. [cited 2018 February 19, 2018]. http://www.iea.cc/whats/
Jencks SF, Williams MV, Coleman EA (2009) Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med 360(14):1418–1428
Johnson KB, Fitzhenry F (2006) Case report: activity diagrams for integrating electronic prescribing tools into clinical workflow. J Am Med Inf Assoc 13(4):391–395
Jones PH (2013) Design for care—innovating healthcare experience. Rosenfield Media, Brooklyn
Jun GT, Ward J, Morris Z, Clarkson J (2009) Health care process modelling: which method when? Int J Qual Health Care 21(3):214–224
Jun GT, Ward J, Clarkson P (2010) Systems modelling approaches to the design of safe healthcare delivery: ease of use and usefulness perceived by healthcare workers. Ergonomics 53(7): 829–847
Kanse L, Van der Schaaf TW, Vrijland ND, Van Mierlo H (2006) Error recovery in hospital pharmacy. Ergonomics 49(5–6):503–516
Kaplan GS, Bo-Linn G, Carayon P, Pronovost P, Rouse W, Reid P et al (2013) Bringing a systems approach to health. Institute of Medicine and National Academy of Engineering, Washington, DC
Kianfar S (2016) Understanding care coordination activities performed for chronically ill patients. ProQues: University of Wisconsin-Madison, Madison, Wisconsin
Kleiner BM (2008) Macroegonomics: work system analysis and design. Hum Fact 50(3):461–467
Kohn LT, Corrigan JM, Donaldson MS (eds) (1999) To err is human: building a safer health system. National Academy Press, Washington, DC
Kummerow Broman K, Kensinger C, Hart H, Mathisen J, Kripalani S (2017) Closing the loop: a process evaluation of inpatient care team communication. BMJ Qual Saf 26(1):30–32
Leplat J (1989) Error analysis, instrument and object of task analysis. Ergonomics 32(7):813–822
Lesar TS, Briceland L, Delcoure K et al (1990) Medication prescribing orders in a teaching hospital. J Am Med Assoc 263:2329–2334
Maliski SL, Clerkin B, Litwin MS (2004) Describing a nurse case manager intervention to empower low-income men with prostate cancer. Oncol Nurs Forum 31(1):57–64
Marcotte L, Kirtane J, Lynn J, McKethan A (2015) Integrating health information technology to achieve seamless care transitions. J Patient Saf 11(4):185–190
McCarthy S, O’Raghallaigh P, Woodworth S, Lim YL, Kenny LC, Adam F (2016) An integrated patient journey mapping tool for embedding quality in healthcare service reform. J Decis Syst 25(Suppl 1):354–368
McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft SA et al (2007) Closing the quality gap: a critical analysis of quality improvement strategies (vol. 7: Care coordination). Agency for Healthcare Research and Quality (US), Rockville
Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS (2001) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 163(5):1256–1276
Pinaire J, Azé J, Bringay S, Landais P (2017) Patient healthcare trajectory. An essential monitoring tool: a systematic review. Health Inf Sci Syst 5(1):1
President’s Council of Advisors on Science and Technology (2014) Report to the President, better health care and lower costs : accelerating improvement through systems engineering. Executive Office of the President, President’s Council of Advisors on Science and Technology, Washington, DC
Reay SD, Collier G, Douglas R, Hayes N, Nakarada-Kordic I, Nair A et al (2017) Prototyping collaborative relationships between design and healthcare experts: mapping the patient journey. Design Health 1(1):65–79
Reid PR, Compton WD, Grossman JH, Fanjiang G (2005) Building a better delivery system. A New engineering/health care partnership. The National Academies Press, Washington, DC
Sawyer S, Tapia A (2006) Always articulating: theorizing on mobile and wireless technologies. Inf Soc 22(5):311–323
Schultz K, Carayon P, Hundt AS, Springman SR (2007) Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences. Cogn Technol Work 9(4):219–231
Shekelle PG, Wachter R, Pronovost P, Schoelles K, McDonald K, Dy S et al (2013a) Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Agency for Healthcare Research and Quality, Rockville. Contract no.: AHRQ publication no.13-E001-EF
Shekelle PG, Pronovost PJ, Wachter RM, McDonald KM, Schoelles K, Dy SM et al (2013b) The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 158(5 Pt 2):365–368
Siemieniuch CE, Sinclair MA (2005) The analysis of organisational processes. Evaluation of human work, 3rd edn. CRC Press, New York, pp 977–1008
Simsekler MCE, Ward JR, Clarkson PJ (2018a) Design for patient safety: a systems-based risk identification framework. Ergonomics 61(8):1046–1064
Simsekler MCE, Ward JR, Clarkson PJ (2018b) Evaluation of system mapping approaches in identifying patient safety risks. Int J Qual Health Care 30(3):227–233
Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T (2013) In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med 11(3):272–278
Smith MJ, Carayon-Sainfort P (1989) A balance theory of job design for stress reduction. Int J Ind Ergon 4(1):67–79
Strauss AL (1985) Work and the division of labor. Sociol Quart 26(1):1–19
Thomsen LA, Winterstein AG, S⊘ndergaard B, Haugb⊘lle LS, Melander A (2007) Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother 41(9):1411–1426
van Tilburg CM, Leistikow IP, Rademaker CMA, Bierings MB, van Dijk ATH (2006) Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual Saf Health Care 15(1):58–63
Tomcavage J, Littlewood D, Salek D, Sciandra J (2012) Advancing the role of nursing in the medical home model. Nurs Admin Q 36(3):194–202
Trebble TM, Hansi N, Hydes T, Smith MA, Baker M (2010) Process mapping the patient journey: an introduction. Br Med J 341:394–401
Unertl KM, Weinger MB, Johnson KB, Lorenzi NM (2009) Describing and modeling workflow and information flow in chronic disease care. J Am Med Inf Assoc 16(6):826–836
Unertl KM, Johnson KB, Lorenzi NM (2012) Health information exchange technology on the front lines of healthcare: workflow factors and patterns of use. J Am Med Inf Assoc 19(3):392–400
Vincent C, Amalberti R (2016) Safer healthcare—strategies for the real world. Springer Open, New York
Vincent C, Aylin P, Franklin BD, Holmes A, Iskander S, Jacklin A et al (2008) Is health care getting safer? Br Med J 337(7680):1205–1207
Vincent C, Carthey J, Macrae C, Amalberti R (2017) Safety analysis over time: seven major changes to adverse event investigation. Implement Sci 12(1):151
Wachter RM (2010) Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood) 29(1):165–173
Walker JM, Carayon P (2009) From tasks to processes: the case for changing health information technology to improve health care. Health Aff 28(2):467–477
Ward BW, Schiller JS, Goodman RA (2014) Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis 11:E62
Werner NE, Malkana S, Gurses AP, Leff B, Arbaje AI (2017) Toward a process-level view of distributed healthcare tasks: medication management as a case study. Appl Ergon 65:255–268
Werner NE, Tong M, Borkenhagen A, Holden RJ (2018a) Performance-shaping factors affecting older adults’ hospital-to-home transition success: a systems approach. Gerontologist
Werner NE, Jolliff AF, Casper G, Martell T, Ponto K (2018b) Home is where the head is: a distributed cognition account of personal health information management in the home among those with chronic illness. Ergonomics 61(8):1065–1078
Westbrook JI, Rob MI, Woods A, Parry D (2011) Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf 20(12):1027–1034
Wetterneck TB (2012) Error recovery in health care. In: Carayon P (ed) Handbook of human factors and ergonomics in health care and patient safety, 2nd edn. Taylor & Francis, Boca Raton, pp 763–774
Wetterneck TB, Skibinski KA, Roberts TL, Kleppin SM, Schroeder M, Enloe M et al (2006) Using failure mode and effects analysis to plan implementation of smart intravenous pump technology. Am J Health Syst Pharm 63:1528–1538
Wetterneck TB, Hundt AS, Carayon P (2009) FMEA team performance in health care: a qualitative analysis of team member perceptions. J Patient Saf 5(2):102–108
Wooldridge AR, Carayon P, Hundt AS, Hoonakker PLT (2017) SEIPS-based process modeling in primary care. Appl Ergon 60:240–254
Xie A, Carayon P (2015) A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety. Ergonomics 58(1):33–49
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This research was supported by the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS), Grant UL1TR000427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Carayon, P., Wooldridge, A.R. (2020). Improving Patient Safety in the Patient Journey: Contributions from Human Factors Engineering. In: Smith, A. (eds) Women in Industrial and Systems Engineering. Women in Engineering and Science. Springer, Cham. https://doi.org/10.1007/978-3-030-11866-2_12
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