Abstract
Identifying systems problems is essential in improving patient safety. The field of human factors has established many methodologies for identifying and resolving systems problems. In this paper, we use the case of instrument trays for chest-tube placement to illustrate a human factors methodology in identifying systems problems. A questionnaire was developed to solicit problems associated with chest-tube trays. Reported problems included accidental injuries to operators, such as needle sticks. Short video clips from 49 chest-tube placements were shown to subject matter experts, who also filled in a questionnaire about their opinions on chest-tube trays. Three types of problems were identified with chest-tube trays that may lead to injuries to the operator and/or harm to the patient: the position, constellation, and content of the chest-tube tray. Using expert reviews of video clips helped identify systems problems associated with instrument trays. We believe that videos can complement the current design practices of expert consensus.
Get full access to this article
View all access options for this article.