Mapeamento prospectivo de fatores de risco no sistema sociotécnico de assistência à saúde

Orientador: Saide Jorge CalilTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Engenharia Elétrica e de ComputaçãoResumo: O grande número de mortes evitáveis na área de saúde revela a necessidade de mudar o mo-do como o sistema lida com eventos adversos. Apesar de esforços para promover uma abor-dagem sistêmica ao gerenciamento de risco, a cultura da culpa ainda predomina. O resultado é a resistência generalizada à investigação de incidentes e a incapacidade de promover mu-danças sistêmicas duradouras. O problema é amplificado pelo uso de ferramentas que se limitam aos fatores de risco no nível do ambiente de trabalho. O objetivo primário deste estudo é desenvolver um método prospectivo para mapear fatores de risco em múltiplos ní-veis hierárquicos do sistema de cuidado à saúde que possam contribuir com a ocorrência de eventos adversos no ambiente de trabalho. A maior parte das referências usadas nesta pes-quisa está associada a fatores de risco e gerenciamento de risco no cuidado à saúde, a mode-los de formação de acidentes e a ferramentas de gerenciamento de risco aplicadas na área de cuidado à saúde e em outras áreas. Como nenhum sistema ou ferramenta única pareceu completamente compatível com o objetivo primário deste trabalho, um conjunto básico de conceitos de gerenciamento de risco foi extraído das referências, especialmente do modelo do `Queijo Suíço¿ de Reason e da estrutura sociotécnica de Rasmussen. Os conceitos foram agrupados num modelo de formação de acidentes híbrido que abrange interações entre ele-mentos do ambiente de trabalho e malhas de controle sociotécnicas. O modelo foi então usa-do como base para o desenvolvimento de um método prospectivo para o mapeamento de fatores de risco. Devido aos requisitos de escopo, o Mapa de Fatores de Risco resultante to-ma emprestados elementos estruturais do AcciMap, de Rasmussen e pode mesmo ser consi-derado como inspirado por ele, embora tenha como foco análises prospectivas, não investi-gações retrospectivas de incidentes críticos. Três estudos de caso foram feitos como teste para o método: o primeiro foi baseado num relatório de avaliação de risco feito com uma ferramenta diferente de gerenciamento de risco; o segundo se concentrou no nível regulató-rio do sistema brasileiro de cuidado à saúde; e o terceiro foi um mapa genérico de fatores de risco baseado na literatura sobre bombas de infusão. Os resultados mostram que o método pode ser usado prospectivamente e que ele abrange os múltiplos níveis hierárquicos do sis-tema sociotécnico de cuidado à saúde. A natureza distinta dos estudos de caso mostra que o método é flexível o bastante para ser aplicado a uma variedade de objetivos e escopos e, se adaptado, também a outras áreas. O Mapa de Fatores de Risco é trabalhoso e a qualidade das análises depende da experiência dos analistas, mas estudos adicionais são necessários para avaliar sua efetividade em comparação com outras ferramentas de avaliação de risco, espe-cialmente o AcciMap. Outra limitação do Mapa de Fatores de Risco é sua natureza predomi-nantemente qualitativa, que reduz sua utilidade para a priorização de correções no sistema. Pesquisas futuras podem reduzir essa limitação pela integração dos Mapas de Fatores de Risco com dados quantitativos de sistemas de notificação de incidentesAbstract: The high volume of preventable deaths in health care reveals the necessity of adjusting how the system deals with adverse events. Despite efforts to promote a systemic approach to risk management, the culture of blame is still prevalent. The result is a general resistance to in-vestigating incidents and inability to promote lasting systemic changes. The problem is am-plified by the use of tools limited to risk factors at the workspace level of the system. The primary objective of this study is to develop a prospective method to map risk factors at mul-tiple hierarchical levels of the health care system that may contribute to the occurrence of adverse events at the workspace level. Most references used in this research are related to risk factors and risk management in health care, to accident causation models, and to risk management tools employed in health care and elsewhere. Because no single system or tool seemed fully compatible with the primary objective, a set of basic risk management concepts was extracted from the references, especially Reason¿s Swiss Cheese Model and Rasmus-sen¿s Socio-Technical framework. The concepts were assembled into a hybrid accident cau-sation model that encompasses both workspace element interactions and socio-technical controls. The model was then used as the foundation for developing a prospective risk fac-tors mapping method. Due to scope requirements, the resulting Risk Factors Map borrows structure elements from Rasmussen¿s AcciMap and may be considered inspired by it, though it is focused on prospective analyses, not retrospective critical incident investigations. Three case studies were conducted as a test of the method: the first one was based on a risk assessment report made with a different risk management tool, the second was focused at the regulatory level of the Brazilian health care system, and the third one was a generic Risk Factors Map based on the literature on infusion pumps. The results show the method can be used prospectively and it encompasses the multiple hierarchical levels of the socio-technical health care system. The distinct nature of the case studies shows the method is flexible enough to be applied to a variety of objectives and scopes and, with adaptations, also to oth-er domains. The Risk Factors Map requires much time to be completed and the quality of analyses depends on the expertise of the analysts, but additional studies are required to as-sess its effectiveness in comparison with other risk assessment tools, especially the Acci-Map. Another limitation of the Risk Factors Map is its predominantly qualitative nature, which reduces its usefulness for prioritizing system corrections. Further research may re-duce this limitation by integrating Risk Factors Maps with quantitative data from incident report systemsDoutoradoEngenharia BiomedicaDoutor em Engenharia Elétrica141021/2009-8CNP

Designing an Adaptive Web Navigation Interface for Users with Variable Pointing Performance

Many online services and products require users to point and interact with user interface elements. For individuals who experience variable pointing ability due to physical impairments, environmental issues or age, using an input device (e.g., a computer mouse) to select elements on a website can be difficult. Adaptive user interfaces dynamically change their functionality in response to user behavior. They can support individuals with variable pointing abilities by 1) adapting dynamically to make element selection easier when a user is experiencing pointing difficulties, and 2) informing users about these pointing errors. While adaptive interfaces are increasingly prevalent on the Web, little is known about the preferences and expectations of users with variable pointing abilities and how to design systems that dynamically support them given these preferences. We conducted an investigation with 27 individuals who intermittently experience pointing problems to inform the design of an adaptive interface for web navigation. We used a functional high-fidelity prototype as a probe to gather information about user preferences and expectations. Our participants expected the system to recognize and integrate their preferences for how pointing tasks were carried out, preferred to receive information about system functionality and wanted to be in control of the interaction. We used findings from the study to inform the design of an adaptive Web navigation interface, PINATA that tracks user pointing performance over time and provides dynamic notifications and assistance tailored to their specifications. Our work contributes to a better understanding of users' preferences and expectations of the design of an adaptive pointing system

Aerospace medicine and biology: A continuing bibliography with indexes (supplement 338)

This bibliography lists 139 reports, articles and other documents introduced into the NASA Scientific and Technical Information System during June 1990. Subject coverage includes: aerospace medicine and psychology, life support systems and controlled environments, safety equipment, exobiology and extraterrestrial life, and flight crew behavior and performance

Proceedings of the Human Factors and Ergonomics Society Europe Chapter 2014 Annual Conference:Human Factors in high reliability industries

On the occasion of the 2014 Meeting in Lisbon, Portuga

Proceedings of the Human Factors and Ergonomics Society Europe Chapter 2014 Annual Conference:Human Factors in high reliability industries

On the occasion of the 2014 Meeting in Lisbon, Portuga

Proceedings of the Human Factors and Ergonomics Society Europe Chapter 2014 Annual Conference:Human Factors in high reliability industries

On the occasion of the 2014 Meeting in Lisbon, Portuga