patient handoffs a cognitive systems engineering perspective
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Patient Handoffs: A Cognitive Systems Engineering Perspective. November 11, 2011. What is cognitive systems engineering?. Human Factors (‘50) : interdisciplinary human-centered approach to addressing design challenges.

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Presentation Transcript
What is cognitive systems engineering?

Human Factors (‘50):interdisciplinary human-centered approach to addressing design challenges

Cognitive Systems Engineering (‘80):engineering a system of human and machine agents performing cognitive tasks in a domain

cognitive systems engineering is coping with complexity
Cognitive Systems Engineering is... Coping with Complexity
  • situations
  • scenarios
  • tasks
  • domains

In challenging:

  • expertise
  • knowledge
  • strategies

With experts:

  • artifacts
  • other agents

Supported by:

Cognitive Triad

…In The Era of Complexity




Augmented Cognitive Capacity

Integrated Capabilities

NASA: Handoffs Help to Recognize Unexpected Events

…making sure they correctly interpret nominal situations as being nominal, and recognize early in the game off-nominal signatures …The handover's critical … in how they have correctly detected and communicated the situational status*

*TandiBagian, e-mail, January 31, 2000

Potential Lessons for Patient Handoffs

Communicate whether an event is expected or unexpected

Include degree of diagnostic uncertainty

Provide evidence for diagnostic judgments to allow errors to be detected

Be receptive to having reasoning challenged

NASA: Handoffs are Given to Someone Who Already Knows a Lot

Along with having a base of knowledge [from working the day before], the incoming folks likely have seen the anomaly/fault log, the events that [NASA] is currently tracking, have been listening to the loops or watching [NASA TV]*

*TandiBagian, e-mail, January 31, 2000

Potential Lessons for Patient Handoffs

Distinguish between novel and ‘handback’ information

For handback information: Emphasize what has happened since the person was last directly responsible and who will do pending actions

Expect active engagement from person accepting handoff

NASA: Handoffs are ‘Bottom Line’

and Details on Demand

Folks are mentored to understand that handovers are to be efficient, pass along what needs to be understood, verify correct situational awareness …it's a real skill that comes hard to some folks who would naturally try to provide details and descriptions, rather than primarily the bottom line.*

*TandiBagian, e-mail, January 31, 2000

Potential Lessons for Patient Handoffs

Emphasize synthesis and interpretation

Use ‘on the job’ coaching to minimize details and descriptions

Minimize social elements during handoff

Triage ‘most important first’ in case handoff is cut short

Summary of CSE Perspective on

Handoff Opportunities

  • Efficiency could be increased by:
    • Reducing handback information
    • Coaching on ‘bottom line’ interpretation and synthesis skill
    • Providing details on demand
  • System resilience could be increased with:
    • Faster responses to unexpected events
    • Detecting erroneous situation assessments
    • Clarifying responsibility for pending actions
Thank you for your attention

Partial funding provided by the 2010-2011 Hospira Research Grant of the National Patient Safety Foundation