Closing Threat Windows: Researchers Pinpoint Workflow Disruptions in Healthcare Settings 

Cohen, who received her Ph.D. in Human Factors in May, says the key to accurately collecting data on workflow disruptions was to stay out of the sterile area, but to keep a close eye on doctors, nurses and support staff.

Now a research scientist at Cedars-Sinai Medical Center, Cohen’s work documents the variety of distractions that can pull the attention of doctors and nurses away from their patients.

On average, trauma-care doctors or their staff members were disrupted once every two minutes, Cohen reports in her article, “Using Broken Windows Theory as the Backdrop for a Proactive Approach to Threat Identification in Health Care.” The paper, published online in 2016 by the Journal of Patient Safety, was one of 10 research articles Cohen published during her time at Embry-Riddle.

“It’s all about optimizing performance,” says Professor and Human Factors and Systems Chair Scott Shappell. “We’re talking about doctors with a minimum of nine years of post-baccalaureate education, so they’re highly trained and very good at what they do. Other groups have looked at human and medical error. That’s not our focus. Instead, we want to know what’s keeping these talented people from performing at 100 percent all of the time?”

Chaotic Environments Increase Risks

Cohen and Embry-Riddle Human Factors Professor Albert J. Boquet, who is a lead author on the paper with Cohen, borrowed “broken windows theory” from the criminology field to explain their research. The theory states that as minor crimes such as vandalism, litter and public drinking are allowed to continue unchecked in a neighborhood, it sets the stage for more serious crimes and general disorder. Ultimately, residents may begin to fear for their safety and stop investing in the area.

Though the theory is controversial in relation to decisions about policing tactics in different communities, Boquet says that from a social sciences standpoint, it provides a useful way to think about disorder in healthcare settings. “The analogy of a neighborhood fits nicely with the socio-technical environment in healthcare,” he says. “If there is a chaotic environment in a surgical unit, communication, coordination and other workflow disruptions can increase, order is degraded and patient care can be undermined.”

Pulling the RIPCHORD 

Before the researchers could start identifying and counting the “broken windows” that disrupt workflow in healthcare settings, they needed an assessment tool. While he was in the military, Shappell teamed up with Doug Wiegmann, now a faculty member at the University of Wisconsin-Madison, to create the Human Factors Analysis and Classification System (HFACS) framework, a well-regarded tool for identifying human performance failures that contributed to aircraft accidents.

Turning his attention to medical research, Shappell collaborated with colleagues at the Medical University of South Carolina and Clemson University to design a human factors framework specific to healthcare. The result was a system for classifying workflow disruptions: RIPCHORD (Realizing Improved Patient Care through Human-Centered Operating Room Design).

With guidance from Shappell and Boquet, Cohen took the RIPCHORD tool and expanded it to encompass Threat Windows Analysis (RIPCHORD-TWA).

Embedded in the Trauma Center

With this new framework in hand, Cohen and other human factors graduate students acted as “on call” members of the emergency room team for her Journal of Patient Safety study. “If we got a page, we would jump up and race to the hospital,” Cohen says.

They logged their observations in real time on Windows-based tablets using a modified computer platform created in the Embry-Riddle Medical Human Factors lab. Thorough training helped ensure the accuracy of each researcher’s results.

Together, the researchers observed and assessed 34 trauma cases for the study. They collected data from the time a patient arrived in the resuscitation bay, all the way through imaging, if required. “Anything that was a hindrance, a holdup or a hang-up for the medical provider was noted,” Cohen says.

A total of 576 disruptions were identified, or an average of 17 disruptions per case. The disruptions included communication (or lack thereof); interruptions from people, devices or accidental spilling/dropping incidents; environmental and equipment challenges; personnel coordination; and usability.

The physicians, circulating nurses and others in the room usually don’t notice these breaks in the workflow, or “threat windows,” says Boquet, yet all medical professionals face them on a daily basis. 

“We think of threat windows as the normalization of deviance. The more disruptions you have to work around, the more that becomes normal,” he explains.

Eliminating the Error Space

Boquet calls the time it takes to resolve each disruption and refocus on the task at hand the “error space” – the time when mistakes are most likely to occur. “It represents the cognitive disengagement between the practitioner and the patient,” he says.

He hopes Embry-Riddle research will help hospital administrators identify problems that create and expand the error space, so workflow disruptions can be mitigated or eliminated.

Cohen agrees. “It’s all about making a difference,” she says. “We want to help identify human factors issues in healthcare that may lead to catastrophe in the future. We want to approach patient safety in a proactive way – much like preventative medicine.” 

New Aerospace Physiology Program Offers Pre-Med Pathway

Individuals seeking careers in medical research, or those who want to improve the health and well-being of pilots, astronauts, flight crew members and air or space travelers, now have a degree program custom-made for them.

This fall, Embry-Riddle Aeronautical University’s Daytona Beach Campus launched a Bachelor of Science in Aerospace Physiology – believed to be the first undergraduate program of its kind in the nation.

The program offers real-world experience in clinical settings, thanks to a partnership between the university and six local Florida Hospital branches. Florida Hospital helped design the curriculum, which exposes students to advanced patient-care techniques and clinical instrumentation. Additionally, the hospital will provide two practicum clinical courses.

“An undergraduate degree in aerospace physiology from Embry-Riddle will put students on track to enter medical school, or to pursue careers in the military and civilian sectors,” says Karen Gaines, dean of the university’s College of Arts and Sciences. “Studying cellular function in space can help advance scientific research, human healthcare and life on Earth.”

The program is supported both by a letter of commitment from Florida Hospital and a substantial gift from Florida-based philanthropist Helen M. Wessel, a longtime champion of higher education. Through her generosity, Embry-Riddle will establish a pivotal faculty position, titled the Dr. Robert H. Wessel and Dr. Helen M. Wessel Endowed Chair for Aerospace Physiology.

The new program greatly expands the university’s opportunities for research and development funding, including potential partnerships with Kennedy Space Center, NASA and others, Gaines says.

Editor’s Note: This article was originally published in the Fall 2017 edition of ResearchER magazine (Vol. 1, No. 2). The ResearchER archives can be found on Scholarly Commons.