Preventing Blood Component Administration Errors

By far the greatest risk to patients is human error; receiving the wrong blood component or one that is not compatible. A fatality subsequent to a blood transfusion is a devastation one cannot quantify. Blood transfusions are a routinely performed life saving intervention in the inpatient acute care hospital setting. Although blood transfusions can be extremely beneficial when delivered correctly, the risks associated with receiving incorrect blood components are severe and potentially fatal. The blood component administration process in the inpatient acute care hospital setting is dependent upon the systematic function of both communication and interaction technology. Therefore, the Institute for Healthcare Improvement’s Idealized Design of Clinical Practice (IDCOP) program (IDCOP), Interaction, provided the clinical framework for this project. A mixed closed, thirty-four bed critical care unit, was utilized for this project, which presented many opportunities to evaluate and trial the blood component administration process. Lewin’s change theory, unfreeze, move, and refreeze provided the methodology for this project. We determined, enhanced communication was needed and implemented a checklist to be dispensed along with the blood component to assist healthcare workers in completing all steps in the process. Real time audits were conducted of dispensing, administering, and monitoring of blood components after administration, yielding quantitative data for further analysis. Multiple PDSA’s were conducted each time the checklist was revised and implemented. A transfusion navigator was put into the electronic charting system to assist healthcare workers with the steps associated with blood component administration. To aid in sustainability a teach-back process to confirm competency was implemented for nurses to be initiated in the event of fallouts or errors improve knowledge retention and improve outcomes. The interventions put in place during this project were both effective and sustainable as the goal to reduce blood component administration errors by 50% by the end of the first quarter of 2016 was attained and the new process has been included in new policies

Impact of Health Information Technology Patient Education with Teach-Back on Patient Satisfaction and Hospital Readmissions

Background: With the advances in medical care, patients are being asked to manage more complicated self-care regimens, and there is often a gap between what the nurse teaches and what the patient understands. This can lead to re-hospitalizations that are burdensome for patients and are costly to the American healthcare system. The Department of Health and Human Services (DHHS) challenged healthcare organizations to leverage technology that engages patients in self-management support and encourages clinician use of patient-centered communication techniques, such as teach-back. Purpose: The purpose of this project is to evaluate the use of health information technology along with an evidence-based practice communication technique, teach-back, to improve patient satisfaction, and decrease hospital readmissions. Methods: A descriptive, quasi-experimental study design using pre and post-test comparisons was used to make comparisons between thirty-day readmission rates, Consumer Assessment of Healthcare Providers and Systems (CAHPS) with transition of care, and a nurse satisfaction survey. Results: There was no evidence of statistical significance in the comparison of outcomes before and after the intervention. The nurses provided teach-back following the video clips with 16% of the patients so the intervention was not implemented by the staff as planned. However, 90% of the patients that answered the Interactive Patient Care System (IPC) satisfaction survey before discharge responded that they were able to easily use the system, it helped them understand more about their health condition and how to care for themselves, and it positively impacted their hospital stay. While the results are not statistically significant, they are still sufficiently conclusive to support further study to analyze the effectiveness of using an IPC system with evidence based practice teaching techniques

Distance support in-service engineering for the high energy laser

The U.S. Navy anticipates moving to a shipboard high-energy laser program of record in the fiscal year 2018 and achieving an initial operational capability by 2020. The design of a distance support capability within the high-energy laser system was expected to assist the Navy in reaching this goal. This capstone project explored the current Navy architecture for distance support and applied system engineering methodologies to develop a conceptual distance support framework with application to the high-energy laser system. A model and simulation of distance support functions were developed and used to analyze the feasibility in terms of performance, cost, and risk. Results of this capstone study showed that the implementation of distance support for the high-energy laser system is feasible and would reduce the total ownership cost over the life of the program. Furthermore, the capstone shows that moving toward the team’s recommended distance support framework will address current gaps in the Navy distance support architecture and will provide a methodology tailored to modern enterprise naval systems.http://archive.org/details/distancesupporti1094545248Approved for public release; distribution is unlimited

ARCHITECTURE FOR A CBM+ AND PHM CENTRIC DIGITAL TWIN FOR WARFARE SYSTEMS

The Department of the Navy’s continued progression from time-based maintenance into condition-based maintenance plus (CBM+) shows the importance of increasing operational availability (Ao) across fleet weapon systems. This capstone uses the concept of digital efficiency from a digital twin (DT) combined with a three-dimensional (3D) direct metal laser melting printer as the physical host on board a surface vessel. The DT provides an agnostic conduit for combining model-based systems engineering with a digital analysis for real-time prognostic health monitoring while improving predictive maintenance. With the DT at the forefront of prioritized research and development, the 3D printer combines the value of additive manufacturing with complex systems in dynamic shipboard environments. To demonstrate that the DT possesses parallel abilities for improving both the physical host’s Ao and end-goal mission, this capstone develops a DT architecture and a high-level model. The model focuses on specific printer components (deionized [DI] water level, DI water conductivity, air filters, and laser motor drive system) to demonstrate the DT’s inherent effectiveness towards CBM+. To embody the system of systems analysis for printer suitability and performance, more components should be evaluated and combined with the ship’s environment data. Additionally, this capstone recommends the use of DTs as a nexus into more complex weapon systems while using a deeper level of design of experiment.Outstanding ThesisCivilian, Department of the NavyCommander, United States NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyApproved for public release. Distribution is unlimited

Human Performance Contributions to Safety in Commercial Aviation

In the commercial aviation domain, large volumes of data are collected and analyzed on the failures and errors that result in infrequent incidents and accidents, but in the absence of data on behaviors that contribute to routine successful outcomes, safety management and system design decisions are based on a small sample of non- representative safety data. Analysis of aviation accident data suggests that human error is implicated in up to 80% of accidents, which has been used to justify future visions for aviation in which the roles of human operators are greatly diminished or eliminated in the interest of creating a safer aviation system. However, failure to fully consider the human contributions to successful system performance in civil aviation represents a significant and largely unrecognized risk when making policy decisions about human roles and responsibilities. Opportunities exist to leverage the vast amount of data that has already been collected, or could be easily obtained, to increase our understanding of human contributions to things going right in commercial aviation. The principal focus of this assessment was to identify current gaps and explore methods for identifying human success data generated by the aviation system, from personnel and within the supporting infrastructure

The Use of Mobility Data for Responding to the COVID-19 Pandemic

As the COVID-19 pandemic continues to upend the way people move, work, and gather, governments, businesses, and public health researchers have looked increasingly at mobility data to support pandemic response. This data, assets that describe human location and movement, generally has been collected for purposes directly related to a company's business model, including optimizing the delivery of consumer services, supply chain management or targeting advertisements. However, these call detail records, smartphone-mobility data, vehicle-derived GPS, and other mobility data assets can also be used to study patterns of movement. These patterns of movement have, in turn, been used by organizations to forecast disease spread and inform decisions on how to best manage activity in certain locations.Researchers at The GovLab and Cuebiq, supported by the Open Data Institute, identified 51 notable projects from around the globe launched by public sector and research organizations with companies that use mobility data for these purposes. It curated five projects among this listing that highlight the specific opportunities (and risks) presented by using this asset. Though few of these highlighted projects have provided public outputs that make assessing project success difficult, organizations interviewed considered mobility data to be a useful asset that enabled better public health surveillance, supported existing decision-making processes, or otherwise allowed groups to achieve their research goals.The report below summarizes some of the major points identified in those case studies. While acknowledging that location data can be a highly sensitive data type that can facilitate surveillance or expose data subjects if used carelessly, it finds mobility data can support research and inform decisions when applied toward narrowly defined research questions through frameworks that acknowledge and proactively mitigate risk. These frameworks can vary based on the individual circumstances facing data users, suppliers, and subjects. However, there are a few conditions that can enable users and suppliers to promote publicly beneficial and responsible data use and overcome the serious obstacles facing them.For data users (governments and research institutions), functional access to real-time and contextually relevant data can support research goals, even though a lack of data science competencies and both short and long-term funding sources represent major obstacles for this goal. Data suppliers (largely companies), meanwhile, need governance structures and mechanisms that facilitate responsible re-use, including data re-use agreements that define who, what, where, and when, and under what conditions data can be shared. A lack of regulatory clarity and the absence of universal governance and privacy standards have impeded effective and responsible dissemination of mobility for research and humanitarian purposes. Finally, for both data users and suppliers, we note that collaborative research networks that allow organizations to seek out and provide data can serve as enablers of project success by facilitating exchange of methods and resources, and closing the gap between research and practice.Based on these findings, we recommend the development of clear governance and privacy frameworks, increased capacity building around data use within the public sector, and more regular convenings of ecosystem stakeholders (including the public and data subjects) to broaden collaborative networks. We also propose solutions towards making the responsible use of mobility data more sustainable for longterm impact beyond the current pandemic. A failure to develop regulatory and governance frameworks that can responsibly manage mobility data could lead to a regression to the ad hoc and uncoordinated approaches that previously defined mobility data applications. It could also lead to disparate standards about organizations' responsibilities to the public

Understanding the end user perspective: a multiple-case study of successful health information technology implementation

The United States continues to lag behind other countries in its adoption of health information technology. A failure to increase adoption will jeopardize the nation\u27s ability to reduce medical errors, address the rapid growth of healthcare costs, and enact effective healthcare reform. Health information technology (HIT) implementation success factors as perceived by healthcare executives and industry experts are well documented in the literature. Few studies, however, have focused on the perceptions of HIT end users such as physicians and nurses. The purpose of this exploratory case study was to describe the strategies, actions, and other factors that contribute to the successful implementation of HIT as perceived by 29 HIT end users at a 613-bed adult hospital and 7 end users at a 272-bed children\u27s hospital. Interview data, secondary sources, and investigator observations were analyzed in three phases consistent with the core elements of qualitative data analysis and led to the emergence of eight unique themes which suggest factors that allow or inhibit HIT implementation success. These factors include (a) the end users\u27 understanding of the implementation goals, (b) the appropriateness of the selected HIT system, (c) the usability of the system, (d) the adequacy of the supporting infrastructure, (e) the quality of the end user training, (f) the adequacy of the on-site support, (g) the resulting impact to nursing and physician workflows, and (h) the resulting quality of nursing and physician documentation. Conclusions drawn from the exploration include: (a) communication between the decision-makers and the end users was inadequate; (b) poor usability design, lack of supporting infrastructure, and lack of workflow optimization brought on serious side effects including a decrease in the quality of physician documentation, an emphasis on financially-driven versus care-driven charting, and disruption to provider-patient and physician-nurse relationships; (c) specialized care environments require equally specialized HIT systems if they are to operate optimally; and (d) less end user training prior to implementation in favor of more post-activation on-site support and follow-up training would have represented a more effective use of resources

Improvement in Primary Care Identification of Trauma Symptoms of Foster Care Children

Introduction: Exposure to adverse childhood events (ACEs) is common in foster children. Primary care providers are ideally positioned to advocate for foster care children through early identification and treatment of trauma-related symptoms and diagnoses during routine well-child assessments. Purpose: This quality improvement project sought to institute a standardized trauma assessment instrument, the Childhood Behavioral Checklist (CBCL), to determine if there was an increase in the identification of trauma-related symptoms and diagnoses along with an increase in the rate of referral to mental health care (MHC). Method: This quality improvement project used a descriptive, observational design to complete retrospective and prospective record reviews to measure the number of trauma-related symptoms, diagnoses, and the rate of referral to mental health care before and after implementation of the tool. Results: The average number of trauma-related symptoms identified was higher with the institution of the CBCL (32.2 vs. 3.67 number of symptoms) with a significant difference in the mean rank and distribution of symptoms. There was no change in the number of identified diagnoses or rates of referral to MHC. Implications: The use of a standardized trauma assessment tool increases the identification of trauma-related symptoms in foster care children in the primary care setting. Subsequently, use of the tool may improve documentation of trauma-related symptoms and improve reimbursement for trauma-related diagnoses. More detailed medical records for foster children may also offer greater continuity of care as they are transferred from home to home and provider to provider on interdisciplinary teams

Structural identification: Opportunities and challenges

Some of the significant opportunities and facing successful implementation of the structural identification (St-Id) in civil infrastructure are discussed. The greatest challenges in successful applications of St-Id have emerged as systems integration requirements, requiring mastery in management, modeling and simulation, experimental arts, information technology, and decision-making. Formulating effective policies, strategies, and project-specific designs for improving their performance as systems cannot be expected unless it is understood how infrastructures perform as complex systems. The St-Id may be a means of establishing a quantitative and mechanistic baseline characterization for a newly constructed system similar to a birth certificate. Some major infrastructure owners and consultants have developed an appreciation of the value of St-Id in relation to retrofit design and historic preservation

The Use of Routinely Collected Data in Clinical Trial Research

RCTs are the gold standard for assessing the effects of medical interventions, but they also pose many challenges, including the often-high costs in conducting them and a potential lack of generalizability of their findings. The recent increase in the availability of so called routinely collected data (RCD) sources has led to great interest in their application to support RCTs in an effort to increase the efficiency of conducting clinical trials. We define all RCTs augmented by RCD in any form as RCD-RCTs. A major subset of RCD-RCTs are performed at the point of care using electronic health records (EHRs) and are referred to as point-of-care research (POC-R). RCD-RCTs offer several advantages over traditional trials regarding patient recruitment and data collection, and beyond. Using highly standardized EHR and registry data allows to assess patient characteristics for trial eligibility and to examine treatment effects through routinely collected endpoints or by linkage to other data sources like mortality registries. Thus, RCD can be used to augment traditional RCTs by providing a sampling framework for patient recruitment and by directly measuring patient relevant outcomes. The result of these efforts is the generation of real-world evidence (RWE). Nevertheless, the utilization of RCD in clinical research brings novel methodological challenges, and issues related to data quality are frequently discussed, which need to be considered for RCD-RCTs. Some of the limitations surrounding RCD use in RCTs relate to data quality, data availability, ethical and informed consent challenges, and lack of endpoint adjudication which may all lead to uncertainties in the validity of their results. The purpose of this thesis is to help fill the aforementioned research gaps in RCD-RCTs, encompassing tasks such as assessing their current application in clinical research and evaluating the methodological and technical challenges in performing them. Furthermore, it aims to assess the reporting quality of published reports on RCD-RCTs