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Outcomes, which are the result state or condition from a process or intervention, are essential elements of healthcare system design and an important indicator of performance. They are included in well-known system analysis frameworks such as the Systems Engineering Initiative for Patient Safety (SEIPS) and Cognitive Work Analysis (CWA). However, fewer practical approaches exist for understanding and communicating interactions among healthcare outcomes. This study applies a novel mapping method as a practical approach to collect, aggregate and visualise interrelations among multiple healthcare outcomes. Graphic facilitation mapping sessions with eleven healthcare providers and ten patients with chronic conditions were conducted. Participants created outcome interrelationship maps following a six-step process. Two outcome-based network visualisations were synthesised using network analysis. This outcome-based approach advances how we frame healthcare systems, focussing on accommodating multiple stakeholders' visions, understanding interrelations, and defining trade-offs. This practical approach may complement frameworks such as SEIPS and CWA. Practitioner summary: The presented outcome-based mapping approach can facilitate the understanding of outcomes as part of the interrelated healthcare system. The approach allows the discussion and integration of different stakeholders' outcome priorities to identify critical elements and better inform the development or adaptation of healthcare systems. Abbreviations: SEIPS: engineering initiative for patient safety; CWA: cognitive work analysis; HFE: human factors and ergonomics; AH: abstraction hierarchy; POTS: postural orthostatic tachycardia syndrome; DRM: design research methodology; FA2: forceAtlas2; HbA1c: glycated haemoglobin; NHS: National Health Service; UK: United Kingdom.

La ergonomia (o factores humanos) (E/FH) es una disciplina cientifica que ayuda a mejorar, (re)disenar e implementar sistemas de salud resilientes y seguros que garanticen la seguridad de los pacientes y el bienestar de todos los actores involucrados. A pesar de los beneficios de integrar la E/FH en los sistemas de salud, su diseminacion y aplicacion en America Latina ha sido lenta. Este articulo identifica los aportes en investigacion de la E/FH a los sistemas de salud de America Latina a traves de una revision sistematica de literatura. La revision siguio las directrices PRISMA, realizando la busqueda en ingles, espanol y portugues en las bases de datos Scopus, Web of Science, PubMed y Scielo. Un total de 77 articulos fueron incluidos en la revision y analizados acorde con los cinco dominios en que se ha enfocado la E/FH en los sistemas de salud. Estos dominios incluyen: i) usabilidad de la tecnologia, ii) seguridad del paciente y analisis de incidentes, iii) desempeno y seguridad de los trabajadores, iv) diseno de sistemas, y v) resiliencia de sistemas. La mayoria de los estudios se han centrado en el desempeno y seguridad de los trabajadores y la usabilidad de la tecnologia; mientras que los otros tres dominios han sido menos estudiados. Lo que sugiere la necesidad de incentivar el uso de los dominios de E/FH con un enfoque de diseno de sistemas, resiliencia de sistemas y de analisis de incidentes que han demostrado ser mas eficaces para mejorar los sistemas de salud.

BACKGROUND Understanding how perceptions around immunity certificates are influenced by individual characteristics is important to inform evidence-based policy making and implementation strategies for services around immunity and vaccine certification. OBJECTIVE This study aimed to assess what were the main individual factors influencing people’s perception of the importance of using COVID-19 immunity certificates, including health beliefs about COVID-19, vaccination views, sociodemographics, and lifestyle factors. METHODS A cross-sectional web-based survey with a nationally representative sample in the United Kingdom was conducted on August 3, 2021. Responses were collected and analyzed from 534 participants, aged 18 years and older, who were residents of the United Kingdom. The primary outcome measure (dependent variable) was the participants’ perceived importance of using immunity certificates, computed as an index of 6 items. The following individual drivers were used as the independent variables: (1) personal beliefs about COVID-19 (using constructs adapted from the Health Belief Model), (2) personal views on vaccination, (3) willingness to share immunity status with service providers, and (4) variables related to respondents’ lifestyle and sociodemographic characteristics. RESULTS The perceived importance of immunity certificates was higher among respondents who felt that contracting COVID-19 would have a severe negative impact on their health (β=0.2564; PPP=.001) or experienced an increase in income after the COVID-19 pandemic (β=–0.1287; P=.002) perceived the use of immunity certificates as less important compared to those who were unemployed or had retired or those who had experienced a reduction in their income during the pandemic. CONCLUSIONS The findings of our survey suggest that more vulnerable members in our society (those unemployed or retired and those who believe that COVID-19 would have a severe impact on their health) and people who experienced a reduction in income during the pandemic perceived the severity of not using immunity certificates in their daily life as higher.

Blood transfusion is considered one of the safer aspects of healthcare, however potentially avoidable patient-safety incidents led to 14 deaths in the United Kingdom in 2017. Improvement initiatives often focus on staff compliance with standard operating procedures. This fails to understand adaptations made in a complex, dynamic environment, so the aim of this study is to examine the extent and nature of adaptations at all stages of the vein to vein transfusion process. Thirty-seven employees described sixty-six adaptations in their transfusion practices, showing clear differences between what has been characterised as work-as-imagined (WAI) and work-as-done (WAD). An analysis of the adaptations using the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) shows that triggers for adaptations were mostly staff-related or driven by poor information technology systems, but the resultant adaptations were usually amendments to tasks and processes. The majority of adaptations (83%) were forced – ideal solutions are not possible, so workarounds and coping strategies are required, but some (17%) were proactive – the surrounding system is adequate, but performance is improved by adapting. Managers or colleagues were largely unaware of adaptations made (79%) and, as a result, opportunities may be missed to identify and learn from resilient practices. The Concepts for Applying Resilience Engineering (CARE) model was further articulated in order to shed extra light on triggers and mechanisms. We make a number of suggestions regarding how we can better learn from adaptations and how these could be used to improve the safety of the blood transfusion process.

ObjectivesTo assess what were the main individual factors influencing people’s perception of the importance of using COVID-19 immunity certificates.DesignCross-sectional online survey.SettingNationally representative survey in the UK, conducted on the 3rd of August 2021.ParticipantsResponses from 534 participants, aged 18 and older, residents of the UK.InterventionsThis was a cross-sectional survey and each participant replied to the same set of questions.Primary outcome measure and independent variablesThe primary outcome measure (dependent variable) was the participants’ perceived importance of using immunity certificates, computed as an index of six items. The following individual drivers were used as the independent variables: a) personal beliefs about COVID-19 (using constructs adapted from the Health Belief Model), b) personal views on vaccination, c) willingness to share immunity status with service providers, and d) variables related to respondents’ lifestyle and socio-demographic characteristics.ResultsPerceived importance of immunity certificates was higher among respondents who felt that contracting COVID-19 would have a severe negative impact on their health (β=0.2564, p=0.0000) and felt safer if vaccinated (β =0.1552, p=0.0000). The prospect of future economic recovery positively influenced perceived importance of immunity certificates. Respondents who were employed or self-employed (β=-0.2412, p=0.0010), or experienced an increase in income after the COVID-19 pandemic (β=-0.1287, p=0.0020) perceived less important the use of immunity certificates compared to those who were unemployed or had retired or those who had experienced reduction in their income during the pandemic.ConclusionsThe findings of our survey suggest that more vulnerable members in our society (unemployed or retired and those believing that COVID-19 would have a severe impact on their health) and people who experienced a reduction in income during the pandemic perceived the severity of not using immunity certificates in their daily life as higher.

This article is a preprint and has not been peer-reviewed. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice. Copyright © 2021 The Author(s). The present short communication paper describes the methodological approach of applying the Health Belief Model to the use COVID-19 immunity certificates in the UK. We designed an online survey including an adaptation of the following Health Belief Model constructs: perceived COVID-19 susceptibility, perceived COVID-19 severity, perceived benefits of using immunity certificates, perceived barriers from using immunity certificates, perceived severity of not using immunity certificates, and perceived vaccination views. The online cross-sectional survey conducted on the 3rd of August 2021 gathered responses from 534 participants aged 18 and older, representative of the UK population in terms of gender, age, and ethnicity. AHRC/UKRI COVID-19 Rapid Response, IMMUNE or Immunity Passport Service Design project (Ref. AH/W000288/1).

Background This study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England’s national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used. Methods AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen. The first set was analysed by the first author and the utility and usability were reflected. The second set was analysed collectively by a purposeful sample of patient safety team members, who create the National Patient Safety Alerts from incident-level data and information. All of them attended a 30-min video-based training and a 1.5 h case-based online workshop. Post-workshop individual interviews were conducted to evaluate their perceived utility and usability of each model. Results The patient safety team showed overwhelming support for the utility of the system models as a ‘framework’ that provides a systematic, structured way of looking at an issue and examining the causes, whilst also sharing concerns regarding their usability. AcciMap was viewed useful particularly in providing a visual comprehensive overview of the issue but considered chaotic by some participants due to many arrows between factors. SEIPS was perceived easier to understand due to the familiarity of the structure (Donbedian’s model), but the non-hierarchical format of SEIPS was considered less useful. Conclusions The participants of the study agreed with the high level of utility of both models for their unique strengths, but shared some concern for the usability of them in terms of complexity and further training/coaching time would be required to adopt these models in their daily practices. It is recommended that the gap between HF/E practitioners and patient safety practitioners can be narrowed by strengthening education, and coaching and mentoring relationships between the two groups, led by the increasing number of healthcare practitioners who embrace their membership to HF/E practice.

This study sough to determine the psychological and behavioural factors contributing to the incorrect diagnosis of urinary tract infection in older adults and identify potential interventions that can address the incorrect diagnosis of urinary tract infection in older adults? The findings were that the misdiagnosis of UTI, particularly in older people, is driven by complex, interconnected psychological and behavioural factors, such as lack of knowledge on the role of urine dip testing, bias towards older people, automatic testing, time and resource constraints, pressures from peers and patients and legal pressures. Developing interventions that address the disconnect between knowledge and practice by encompassing both psychological and behavioural factors may improve patient safety and staff satisfaction. Urine dipstick testing in the ED is often misinterpreted, leading to misdiagnosis which may then impact negatively on patient safety; the reasons this knowledge-practice disconnect exists are multi-factorial, but psychological and behavioural factors play a significant role. Systematic approaches incorporating these factors can potentially improve patient safety, efficiency, costs from unnecessary testing and staff satisfaction. The aim of this study was to identify the psychological and behavioural factors influencing clinicians managing older people with possible UTI in urgent care settings, and to develop an improvement roadmap. Michie’s behaviour change wheel and COM-B (Capability, Opportunity, Motivation, Behaviour Change) models were used as the theoretical basis for this study. Semi-structured interviews were undertaken with 21 purposively selected medical and nursing staff in a large urban emergency department in the East Midlands, United Kingdom. Analysis was informed by the framework approach. A participatory design approach was used to develop an improvement roadmap. Key themes emerging from the semi-structured interviews included lack of knowledge on the role of urine dipstick testing, bias towards older people, automatic testing, time and resource constraints, pressures from peers and patients, and fear of the legal consequences of inaction. A thematic networks map indicated complex interactions between psychological and behavioural factors. Among more than 50 different intervention ideas identified by the workshop participants, two interventions were prioritised for implementation: i) controlling the use of dip stick urine tests; ii) providing individualised feedback to staff regarding the outcomes of patients diagnosed and treated for UTI. Psychological and behavioural factors play a significant role in the misdiagnosis of UTI in older people. Systematic approaches incorporating these factors might improve patient outcomes. Future studies should focus on implementation and evaluating their effectiveness and sustainability.

The validity and reliability of human factors and safety science methods are some of the important criteria for judging their appropriateness and utility for accident analysis, however these are rarely assessed. The aim of this study is to take a closer look at the validity and reliability of two systemic accident analysis methods (Accimap and STAMP) by comparing the results of four studies which analysed the same accident (the South Korea Sewol Ferry accident) using two methods. Studies 1 and 2 used Accimap whilst Studies 3 and 4 applied STAMP. The four studies were compared in terms of analysis procedure taken, level of detail, causal factors identified, and the recommendations for improvements suggested by the methods. The results of the causal factor comparison indicate that the reliability (degree of overlap of causal factors identified from the same method, i.e. inter-analyst overlap) of STAMP (65%) is higher than Accimap (38%). The validity (degree of overlap of causal factors identified from two different methods) is as low as 8%. The comparison of recommendations indicates that STAMP-based analyses produce a wider range of recommendations across multiple system levels while Accimap-based analyses tend to focus on whole system-related recommendations. These findings suggest that the use of a more structured method like STAMP can help produce a more reliable accident analysis results.

ObjectivesThe present study explored public’s willingness to use COVID-19 immunity certificates across six different domestic scenarios.DesignCross-sectional online survey.SettingUK representative survey conducted on the 3rdof August 2021.Participants534 UK residents over 18 years old.InterventionsParticipants replied to the same set of questions.Primary and secondary outcome measuresThe primary outcome measure waswillingness to useimmunity certificates across three different domestic settings (1. Visiting the GP for a non-urgent health issue, 2. Dining in a restaurant, and 3. Attending a performance in a theatre). For each setting two options, one prioritisingconvenience(option A) and the otherprivacy(option B), were offered. Our secondary outcome measures were computed indices from items adapted from the Health Belief Model; Attitudes towards sharing immunity status with service providers; Prior to COVID-19 lifestyle. In addition, we recorded data about respondents’ socio-demographic characteristics.ResultsRespondents were more willing to use immunity certificates that prioritisedconvenience, rather thanprivacy, when visiting their GP (92%). However, privacy was more favorable (84%) in the other two settings (dining in a restaurant and going to a theatre) compared toconvenience(39%). Personal beliefs about COVID-19 and immunity certificates were associated with variations in willingness to use these across all scenarios. No variations were observed across socio-demographics and lifestyle.ConclusionsThe findings of this survey suggest that there is notone size fits allsolution for designing immunity certificates. Immunity certificates are complex socio-technical systems, any attempt to implement these for domestic use should be tailored to different settings and user needs. The design of certification services requires a more evidence-based approach and further research is needed to understand how different settings, design elements (likeconvenienceorprivacy) and personal beliefs about the pandemic should inform their design.Strengths and limitations of this studyThis study presents unique knowledge about the public’s willingness to use immunity certificates for domestic purposes where there is very little published research at the moment.The study reports knowledge about the interaction between individual characteristics, domestic settings, and types of immunity certificate design on willingness to use these certificates.UK nationally representative sample for age, gender, and ethnic background, but limited to people who have the means and capacity to use digital technologies (survey administered using Prolific.co).We present evidence-based recommendations for Public Health services and policy makers about the use of immunity certificates in different domestic settings.Since, as to the writing of this paper, COVID-19 certification has not been mandated in the UK, the scenarios used in the survey were hypothetical.

Healthcare needs to be delivered more holistically, in a way that addresses outcomes for different stakeholders at different levels. Systems thinking has conceptually helped the understanding of the increasing complexity of healthcare outcomes. However, little consideration has been given on how to practically apply this concept to holistic outcome understanding to (re)design healthcare systems. Therefore, this paper aims to develop and evaluate a holistic outcome-based approach to healthcare systems co-creation. Participatory mapping workshops and interviews to co-visualise outcomes as an interconnected system were conducted with two groups: twenty-three design practitioners/researchers and twenty-one patients and healthcare service providers. Results emerged from network analysis which identified critical outcomes, disagreements, gaps and opportunities for system (re)design. The results demonstrated the potential role that this approach could have in gathering, communicating and negotiating the complex needs of multiple stakeholders for healthcare system (re)design.

With increasingly complex safety-critical systems like healthcare being developed and managed, there is a need for a tool that permits decision-makers to better understand the complexity, test various strategies and guide effective changes. System Dynamics (SD) modelling is an effective approach that can aid strategic decision-making in healthcare systems but has been underutilised partly due to the challenge of engaging healthcare stakeholders in the modelling process. This paper, therefore, investigates the applicability of a participatory SD approach based on healthcare workers’ perspectives on ease of use (usability) and usefulness (utility). The study developed an interactive simulation dashboard platform which facilitated participatory simulation for exploring various hospital pharmacy staffing level arrangements and their impacts on interruptions, fatigue, workload, rework, productivity and safety. The findings reveal that participatory SD approach can enhance team learning by converging on a shared mental model, aid decision-making and identifying trade-offs. The implications of these findings are discussed as well as experience and lessons learned on modelling facilitation. Practitioner Summary: This paper reports the perspectives of healthcare workers, who were engaged with a participatory system dynamics modelling and simulation process for hospital pharmacy staffing level management. Evaluative feedback revealed that the participatory SD approach can be a valuable tool for participatory ergonomics by helping the participants gain a deeper understanding of the complex dynamic interactions between workload, rework, safety and efficiency. Abbreviations: SD: system dynamics; ETTO: efficiency-thoroughness trade-off

Background (or Rationale): The traditional hospital pharmacy staffing management model does not account for the complex interactions of social, technical, and environmental factors that can affect performance and safety. Conventionally, workload and dispensing errors within the hospital pharmacy system have been analysed on a factor-by-factor level, using linear and static approaches that ignore feedback mechanisms. Purpose: We aimed to explore the potential of a system dynamics approach to modelling staffing level management in a hospital pharmacy. Methods: Qualitative and quantitative system dynamics models were created to simulate dynamic aspects contributing to dispensing backlog and errors in a hospital pharmacy. A baseline scenario was tested in a “normal” condition, and three different staffing level scenarios (fixed, flexible, and equivalent-fixed) were tested in an extreme condition (hospital winter pressures). Results: During hospital winter pressures, the unintended negative effect on rework due to dispensing errors made it more challenging to deal with demand variability. Findings from the scenario-based simulations revealed that a flexible staffing level arrangement, which dynamically adjusts the number of staff to demand variability during winter pressure, is less effective in reducing the amount of rework than maintaining an equivalent-fixed staffing level. Dispensing backlog during winter pressure can be averted or substantially diminished by proactively employing an equivalent-fixed staffing level that accounts for total staff capacity needed vis-a-vis the current workload. Premature release of extra staff and delayed calling of additional staff from wards can have significant impacts on backlog. Conclusions: Our results demonstrate that system dynamics can provide practical insights into staffing level management in a hospital pharmacy, by accounting for dynamic factors causing dispensing backlog and errors and presenting decision-makers with a holistic understanding of elements affecting system safety and performance.

Welcome to this special issue of the IISE Transactions on Ergonomics and Human Factors (Please see a note below about papers in a joint special issue of the IISE Transactions on Healthcare Systems ...

System Dynamics has the potential to study the aspects of complex systems including its likely effect of modifications to structural and dynamic system properties that cannot be achieved with traditional approaches. This paper presents a review of literature addressing safety issues using system dynamics across safety–critical domains. Sixty-three studies were included and classified based on a customised human factors safety taxonomy framework. The thematic analysis of the literature resulted in five themes: external factors, organisational influences, unsafe supervisions, preconditions for unsafe acts and unsafe acts. The findings suggest that using system dynamics can be a potential tool in improving safety. This can be achieved through improved decision-making by basing it on system analysis, analysing past behavioural events in a modelling structure to plan effective safety policies, as well as looking at a holistic approach when analysing accidents.

Construction industry is still one of the most dangerous industries and its fatal work injuries is almost three times higher than the average across all sectors. Previous researchers have attempted to apply more systemic models and methods to improve accident analysis in construction, but few studies have fully encompassed upstream factors such as decisions and actions at the level of the government and regulator in accident analysis. More importantly, no previous study has evaluated the validity and reliability of systemic accident analysis methods in construction. The present study, therefore, has two main aims: to develop a contributing factor classification framework to support systemic accident investigation in construction and to carry out an assessment of its validity and reliability. The classification framework was developed and assessed in two phases. The phase one involved generating a list of contributing factors from the review of 26 articles and the analysis of 532 construction accident reports. Five federal inspectors with expertise in accident investigation were involved in refining the list into 61 contributing factors and categorizing them into six levels of the Accimap framework. The phase two involved in assessing the validity and reliability of the framework with five practitioners in construction sector using three real construction accidents. This study contributes to the development of a contributing factors classification system framework for construction with acceptable validity and reliability.

The South Korea Sewol ferry accident in April 2014 claimed the lives of over 300 passengers and led to criminal charges of 399 personnel concerned including imprisonment of 154 of them as of Oct 2014. Blame and punishment culture can be prevalent in a more hierarchical society like South Korea as shown in the aftermath of this disaster. This study aims to analyse the South Korea ferry accident using Rasmussen's risk management framework and the associated AcciMap technique and to propose recommendations drawn from an AcciMap-based focus group with systems safety experts. The data for the accident analysis were collected mainly from an interim investigation report by the Board of Audit and Inspection of Korea and major South Korean and foreign newspapers. The analysis showed that the accident was attributed to many contributing factors arising from front-line operators, management, regulators and government. It also showed how the multiple factors including economic, social and political pressures and individual workload contributed to the accident and how they affected each other. This AcciMap was presented to 27 safety researchers and experts at 'the legacy of Jens Rasmussen' symposium adjunct to ODAM2014. Their recommendations were captured through a focus group. The four main recommendations include forgive (no blame and punishment on individuals), analyse (socio-technical system-based), learn (from why things do not go wrong) and change (bottom-up safety culture and safety system management). The findings offer important insights into how this type of accident should be understood, analysed and the subsequent response.

Purpose Service networks are inherently complex as they comprise of many interrelated actors, often driven by divergent interests. This can result in imbalance, which refers to a situation where the interests of at least one actor in a network are not secured. Drawing on the “balanced centricity” perspective, the purpose of this paper is to explore the causes of imbalance in complex service networks. Design/methodology/approach Adopting a qualitative case-based approach, this paper examines a public health service network that experienced imbalance that was detrimental to the lives of its users: the Mid-Staffordshire National Health Service (NHS) Trust, UK. Drawing on service-dominant logic and stakeholder theory, case evidence provides insight into the origin and drivers of imbalance in complex public service networks. Findings The origin of imbalance stems from competing institutional logics of various actors (patients/public, employees, managers, regulatory bodies, etc.), but the degree to which these competing institutional logics lead to imbalance is moderated by accountability, communication, engagement, and responsiveness within the service network. Research limitations/implications By uncovering causes of imbalance in complex public service networks, this paper pinpoints important research avenues for developing the balanced centricity perspective. Practical implications The inherent existence of multiple parallel institutional arrangements makes networks imbalanced, but value creation can be achieved when the appropriate mechanisms are fostered to manage balance between divergent logics. Originality/value By examining imbalance as the underlying cause of network dysfunction, this research contributes to understanding of the dynamics in, and performance of, complex public service networks.

Dementia affects 47 million people worldwide (WHO, 2017). It is a collection or consequence of many illnesses with symptoms including deterioration in memory, thinking and behaviour; it is a terminal disease. The fear of dementia leads people to request euthanasia. Euthanasia in dementia rarely happens because the dementia symptoms conflict with the due care criteria; a person requesting euthanasia must confirm the request at time of death and must be undergoing hopeless suffering. Once dementia has progressed, the euthanasia ‘wish’ can no longer be confirmed, and assessing suffering in a person with dementia is hard. Having a reliable dementia diagnosis is essential in order to be able to make a decision for an ‘early’ euthanasia. This paper describes a Speculative Design to explore what options should be considered for receiving a dementia diagnosis in order to plan a death. A branding strategy was developed for the Planned Death company, who advocate an early diagnosis for making endoflife decisions. The branding includes company identity, website, diagnostic kit, diagnostic delivery strategy, and end-of-life support. Additionally a short documentary was developed describing the Planned Death Company’s motivation and a client testimonial. Responses to the documentary were collected with a carefully selected group of participants through a survey and in-depth interviews. The responses were rich and sparked debate. Many new questions aroseto do with patient autonomy and social structures.

Human Factors and Ergonomics (HFE) has played an essential role in increasing the safety and performance of the nuclear energy industry. This review aims to critically examine past HFE research on nuclear safety and provide insights into how HFE approaches can better address current challenges for nuclear safety and future changes (e.g. new technologies, Industry 4.0 and increasing system complexity). The research questions this paper addresses are: (1) what are the common HFE themes and topics that have been applied to nuclear safety? (2) what are the new/key emerging areas/ideas for nuclear safety from an HFE perspective? We reviewed (n = 334) articles from six prominent HFE and safety-focused journals. Articles were classified into a systems framework where research themes and topics could be classified and explored. The findings from the review indicate the primary topics which the nuclear energy industry have focused on have not changed much over time (e.g. safety culture; human error; human-machine interaction) and likewise methods from the 1970s continue to attract attention (e.g. probabilistic risk assessment and human reliability assessment). However, the review demonstrated that more recent topics such as resilience engineering and ideas centred on the ‘Safety-II’ and ‘resilience engineering’ movement are beginning to appear. One of the main conclusions from the review is that there is a need for greater exploration and experimentation of new and emerging areas of interest and their practical implications within the nuclear energy industry.

System diagrams for healthcare incident investigation: ease of understanding and usefulness perceived by healthcare workers [Abstract]

Prevention of patient suicide is a major challenge for mental health services. This study applied both safety I and safety II approaches to gain an understanding of the detection and response process for suicide prevention in community mental health care in order to compare/contrast outputs from each approach. For safety I, 41 suicide incident reports were analysed using a systemic analysis approach. For safety II, interviews with 20 community-based mental health practitioners and managers were conducted asking their know-hows to successful suicide risk detection and response. The five key issues found from the Safety I approach were: (i) an inherent weakness in the interactions between patient and clinician with the presence of uncertainty in the risk detection; (ii) Poor patients’ engagement with services; (iii) Reliance on patients self-presenting in crisis and declining the offered support options; (iv) Delay in treating new patients; (v) Coordination, communication and process issues. On the other hand, the safety II approach revealed a complex decision-making process with the presence of uncertainty and trade-offs between patient clinical need, patient desire, legal and procedural obligations, and resource considerations. It also revealed a strong theme on the importance of peer-support. The results of this study indicate that safety II approach provides valuable insights into how to strengthen the system performance without challenging systemic issues, while system I approach identifies systemic issues and raise questions how to address them. These findings suggest the potential benefit of applying both approaches to quality and safety improvement in healthcare.

Blood transfusion is usually considered to be safe and high-quality. Improvement measures have concentrated on assessing adherence to evidence-based guidelines, but this may fail to understand adaptations staff make in a complex, dynamic environment. Three hospitals in England were visited to trial a method for assessing adaptations in the complete vein to vein transfusion process. An open narrative question encouraged staff to describe adaptations voluntarily and a follow up question scored the level of support received from management. Adaptations can be categorised into: (1) preferred adaptations - developments expected to improve the process; (2) forced adaptations - workarounds and coping strategies when ideal solutions are outside of their control. Preferred adaptations indicate the surrounding system is adequate, but performance/well-being can be improved by adapting. Such adaptations may be good practices and lessons are to be shared. Forced adaptations indicate the surrounding system is inadequate, so people need to adapt to get work done. These may not be desirable, so are unlikely to be suitable for shared learning. Instead the surrounding system probably needs to be assessed or changed. Adaptations are made within staff members’ sphere of influence and although managers may have opportunities to make more resilient changes, frontline staff may be forced to make adaptations to get things done. To facilitate the design of more efficient and safer blood transfusion processes, there is a need for better understanding about how to carry out audit and incident investigation or reporting recognising the adaptations and resilience of healthcare staff.

Dementia affects 47 million people worldwide [1]. It is a collection or consequence of many illnesses with symptoms including deterioration in memory, thinking and behaviour; it is a terminal disease. The fear of dementia may lead people to signing an Advance Euthanasia Directive (AED). AEDs are rarely adhered to because the dementia symptoms conflict with the due care criteria; a person requesting euthanasia must be able to confirm the request at time of death and must be undergoing hopeless suffering. Once dementia has progressed, the euthanasia ‘wish’ can no longer be confirmed, and assessing suffering in a person with dementia is hard. This creates difficulties for physicians supporting patient wishes. Speculative Design is described as a way to prototype other realities [2]. This paper describes a Speculative Design to explore patient autonomy for end-of-life decisions in dementia. A short video was developed to imagine the AED as an implant that would trigger a swift and painless death, once the conditions described in the AED were reached. Data were collected at the DementiaLab conference in Dortmund, Germany, September 2017. The workshop was attended by 15 participants of varying ages and backgrounds. The results found that the Speculative Design had potential to aid discussion between stakeholders, without each party needing to be a specialist. It sparked debate, but with a caveat about the importance of boundaries for awareness of the wider context and sensitivity to inherent bias.

This paper reflects on fundamental ethical issues concerning designing for behavioural change, in order to raise questions about the factors that should be considered by design practitioners when developing interventions. It draws on existing literature on philosophical ethics, moral psychology and design. It proposes a list of ethical questions and considerations to be made throughout the design process. A case study addressing behavioural changes in antibiotics prescriptions (for Urinary Tract Infections) was carried out to demonstrate how the ethical questions identified are asked and considered. We provide a framework for addressing these issues with the hope that it will help minimise the risk of problematic and unethical intervention design processes.

There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual-based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.

Safety is a constant priority for the railway industry and there are numerous hazards in and around the rail system which may result in damage to train and environment, human injury and fatalities. Low levels of human and organisational performance have been shown to be a prime cause of railway accidents and a number of accident models and methods have been developed in order to probe deeper into the role played by organisational factors in accident causation. The Systems-Theoretical Accident Modelling and Processes (STAMP) method for example, represents a promising systematic and systemic way of examining sociotechnical systems such as the railway. Another method, the Human Factors Analysis and Classification System (HFACS), based upon Reason's model of human error in an organisational context, has also proved popular as a human factors accident analysis framework. However, human factors elements are still somewhat limited and under-specified and these managerial and social issues within an organisation are simply regarded as sources of failure in the control constraints of STAMP. HFACS likewise, categorises accident data rather than analysing it in more depth. In this context, a hybrid human and organisational analysis method based on HFACS-STAMP (HFACS-STAMP method for railway accidents, HS-RAs) is proposed to identify and analyse human and organisational factors involved in railway accidents. Using the categories of human errors derived from HFACS and the structured systematic analysis process of STAMP, the HS-RAs method provides a mechanism by which active failures can promulgate across organisations and give a systemic analysis of human error in accidents. Combined with human information processing, the HS-RAs method gives a detailed causal analysis of human errors from receiving information to implement control actions. At last, the HS-RAs method is demonstrated using a case study of the 2011 Yong-Wen railway collision. A number of prominent accident causes of human factors are revealed and necessary countermeasures are proposed to avoid the recurrence of similar accidents. The HFACS-STAMP hybrid method has several advantages and can contribute to railway safety by providing a detailed analysis of the role of human error in railway accidents.

Social enterprises (SE) are valued as innovative solutions to complex problems but require conditions to nurture and support them. Most support systems rely on individuals who already have an SE idea, and there is very little research on understanding what conditions can support to cultivate the willingness and motivation to engage individuals in this activity. An exploratory study was led to understand whether a particular event, Service Design Jams can provide such conditions. The paper introduces the study of the Lufbra Jam, organised at Loughborough University, from which two social enterprises, Crop Club in 2013, and FrenPal in 2014 emerged. Through literature review desirability and feasibility were extrapolated as key variables to the formation process of social enterprises. A focus group with three Lufbra Jam organisers was led to identify important organisational elements of the Jam that were perceived to have an impact on the formation of the successful SE thus influencing the perception of desirability and feasibility of SE in individuals. The integration of the two created a thematic matrix that was used to analyse findings from the research with the participants of the two successful SE Cases. The research findings suggest that Lufbra Jam enabled individuals to identify socially and environmentally focused issues and formulate service solutions that they deemed to be desirable and feasible ideas. It also provided an insight that winning and an enterprising workshop were important SDJ elements that helped teams to recognise their service ideas not only as feasible solutions but as SE opportunity for the team to take forward.

While literature reviews with a large-scale scope are nowadays becoming a staple element of modern research practice, there are many challenges in taking on such an endeavour, yet little evidence of previous studies addressing these challenges exists. This paper introduces a practical and efficient review framework for extremely large corpora of literature, refined by five parallel implementations within a multi-disciplinary project aiming to map out the research and practice landscape of modelling, simulation, and management methods, spanning a variety of sectors of application where such methods have made a significant impact. Centred on searching and screening techniques along with the use of some emerging IT-assisted analytic and visualisation tools, the proposed framework consists of four key methodological elements to deal with the scale of the reviews, namely: (a) an incremental and iterative review structure, (b) a 3-stage screening phase including filtering, sampling and sifting, (c) use of visualisation tools, and (d) reference chasing (both forward and backward). Five parallel implementations of systematically conducted literature search and screening yielded a total initial search result of 146 087 papers, ultimately narrowed down to a final set of 1383 papers which was manageable within the limited time and other constraints of this research work., peer-reviewed

Background The utilisation of good design practices in the development of complex health services is essential to improving quality. Healthcare organisations, however, are often seriously out of step with modern design thinking and practice. As a starting point to encourage the uptake of good design practices, it is important to understand the context of their intended use. This study aims to do that by articulating current health service development practices. Methods Eleven service development projects carried out in a large mental health service were investigated through in-depth interviews with six operation managers. The critical decision method in conjunction with diagrammatic elicitation was used to capture descriptions of these projects. Stage-gate design models were then formed to visually articulate, classify and characterise different service development practices. Results Projects were grouped into three categories according to design process patterns: new service introduction and service integration; service improvement; service closure. Three common design stages: problem exploration, idea generation and solution evaluation - were then compared across the design process patterns. Consistent across projects were a top-down, policy-driven approach to exploration, underexploited idea generation and implementation-based evaluation. Conclusions This study provides insight into where and how good design practices can contribute to the improvement of current service development practices. Specifically, the following suggestions for future service development practices are made: genuine user needs analysis for exploration; divergent thinking and innovative culture for idea generation; and fail-safe evaluation prior to implementation. Better training for managers through partnership working with design experts and researchers could be beneficial.

Diagrammatic representations, such as process mapping and care pathways, have been often used for service evaluation and improvement in healthcare. While a broad range of diagrammatic representations exist, their application in healthcare has been very limited. There is a lack of understanding about how and which diagrams could be usable and useful to health workers. In this study, ten mental health workers were asked to discuss positive and negative issues around their service delivery using one or two diagrams of their choice out of seven different diagrams representing their service: care pathway diagram; organisation diagram; communication diagram; service blueprint; patient state transition diagram; free form diagram; geographic map. Their interactions with diagrams were video-taped for analysis. The patient state transition diagram was the most popular choice in spite of relatively low previous familiarity. The overall findings provided insight into a better use of diagrams in healthcare.

Background There is an increasing recognition that modelling and simulation can assist in the process of designing health care policies, strategies and operations. However, the current use is limited and answers to questions such as what methods to use and when remain somewhat underdeveloped. Aim The aim of this study is to provide a mechanism for decision makers in health services planning and management to compare a broad range of modelling and simulation methods so that they can better select and use them or better commission relevant modelling and simulation work. Methods This paper proposes a modelling and simulation method comparison and selection tool developed from a comprehensive literature review, the research team's extensive expertise and inputs from potential users. Twenty-eight different methods were identified, characterised by their relevance to different application areas, project life cycle stages, types of output and levels of insight, and four input resources required (time, money, knowledge and data). Results The characterisation is presented in matrix forms to allow quick comparison and selection. This paper also highlights significant knowledge gaps in the existing literature when assessing the applicability of particular approaches to health services management, where modelling and simulation skills are scarce let alone money and time. Conclusions A modelling and simulation method comparison and selection tool is developed to assist with the selection of methods appropriate to supporting specific decision making processes. In particular it addresses the issue of which method is most appropriate to which specific health services management problem, what the user might expect to be obtained from the method, and what is required to use the method. In summary, we believe the tool adds value to the scarce existing literature on methods comparison and selection.

The UK health service, which had been diagnosed to be seriously out of step with good design practice, has been recommended to obtain knowledge of design and risk management practice from other safety-critical industries. While these other industries have benefited from a broad range of systems modelling approaches, healthcare remains a long way behind. In order to investigate the healthcare-specific applicability of systems modelling approaches, this study identified 10 distinct methods through meta-model analysis. Healthcare workers' perception on 'ease of use' and 'usefulness' was then evaluated. The characterisation of the systems modelling methods showed that each method had particular capabilities to describe specific aspects of a complex system. However, the healthcare workers found that some of the methods, although potentially very useful, would be difficult to understand, particularly without prior experience. This study provides valuable insights into a better use of the systems modelling methods in healthcare. STATEMENT OF RELEVANCE: The findings in this study provide insights into how to make a better use of various systems modelling approaches to the design and risk management of healthcare delivery systems, which have been a growing research interest among ergonomists and human factor professionals.

Objective The role of process modelling has been widely recognized for effective quality improvement. However, application in health care is somewhat limited since the health care community lacks knowledge about a broad range of methods and their applicability to health care. Therefore, the objectives of this paper are to present a summary description of a limited number of distinct modelling methods and evaluate how health care workers perceive them. Methods Various process modelling methods from several different disciplines were reviewed and characterized. Case studies in three different health care scenarios were carried out to model those processes and evaluate how health care workers perceive the usability and utility of the process models. Results Eight distinct modelling methods were identified and characterized by what the modelling elements in each explicitly represents. Flowcharts, which had been most extensively used by the participants, were most favoured in terms of their usability and utility. However, some alternative methods, although having been used by a much smaller number of participants, were considered to be helpful, specifically in understanding certain aspects of complex processes, e.g. communication diagrams for understanding interactions, swim lane activity diagrams for roles and responsibilities and state transition diagrams for a patient-centred perspective. Discussion We believe that it is important to make the various process modelling methods more easily accessible to health care by providing clear guidelines or computer-based tool support for health care-specific process modelling. These supports can assist health care workers to apply initially unfamiliar, but eventually more effective modelling methods.