Care transitions in the outpatient surgery preoperative process: Facilitators and obstacles to information flow and their consequences

Cognition, Technology and Work

Volumn 9, Issue 4, 2007, Pages 219-231

  Schultz, Kara ^a   Carayon, Pascale ^a   Hundt, Ann Schoofs ^a   Springman, Scott R ^b  

^a University of Wisconsin Madison   (United States)

^b UNIVERSITY OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH   (United States)

Author keywords

Awareness; Handoffs; Outpatient surgery; Patient safety; Transitions of care

Indexed keywords

EID: 35248815968     PISSN: 14355558     EISSN: 14355566     Source Type: Journal    
DOI: 10.1007/s10111-007-0081-0     Document Type: Article

References (39)

1. Baskerville P (2006) A new vision for day surgery. J Perioper Pract 16:327-332
2. Beach C, Croskerry P, Shapiro M (2003) Profiles in patient safety: emergency care transitions. Acad Emerg Med 10:364-367
3. Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T (2004) Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Internal Med 164:545-550
4. Carayon P, Schultz K, Hundt AS (2004) Righting wrong site surgery. Jt Comm J Qual Saf 30:405-410
5. Carayon P, Gurses AP, Hundt AS, Ayoub P, Alvarado CJ (2005a) Performance obstacles and facilitators of healthcare providers. In: Korunka C et al (eds) Change and quality in human service work, vol 4. Hampp Publishers, Munchen, pp 257-276
6. Carayon P, Hundt AS, Alvarado CJ, Springman S, Borgsdorf A, Jenkins L (2005b) Implementing a systems engineering intervention for improved patient safety-example in outpatient surgery. In: Henriksen K et al (eds) Advances in patient safety: from research to implementation, vol 3. Agency for Healthcare Research and Quality, Rockville, MD, pp 305-321
7. Carayon P, Wetterneck TB, Hundt AS, Ozkaynak M, Ram P, DeSilvey J, Hicks B, Roberts TL, Enloe M, Sheth R, Sobande S (2005c) Observing nurse interaction with infusion pump technologies. In: Henriksen K et al (eds) Advances in patient safety: from research to implementation, vol 2. Agency for Healthcare Research and Quality, Rockville, MD, pp 349-364
8. Carayon P, Hundt A, Alvarado C, Springman S, Ayoub P (2006) Patient safety in outpatient surgery: the viewpoint of the healthcare providers. Ergonomics 49:470-485
9. Clancy CM (2006) Care transitions: a threat and an opportunity for patient safety. Am J Med Qual 21:415-417
10. Coleman EA, Berenson RA (2004) Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med 141:533-536
11. Cook RI, Render M, Woods DD (2000) Gaps in the continuity of care and progress on patient safety. Br Med J 320:791-794
12. Cooper JB (1989) Do short breaks increase of decrease anesthetic risk? J Clin Anesth 1:228-231
13. Cooper JB, Long CD, Newbower RS, Philip JH (1982) Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology 56:456-461
14. Dovey SM, Meyers DS, Phillips RL, Green LA, Fryer GE, Galliher JM, Kappus J, Grob P (2002) A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care 11:233-238
15. Drury J, Williams M (2002) A framework for role-based specification and evaluation of awareness support in synchronous collaborative applications. In: Paper presented at the proceedings of the 11th IEEE international workshops on enabling technologies: Infrastructure for Collaborative Enterprises, Pittsburgh, PA
16. Elder NC, Vonder Meulen MB, Cassedy A (2004) The identification of medical errors by family physicians during outpatient visits. Ann Fam Med 2:125-129
17. Endsley MR (1988) Situation awareness global assessment technique (SAGAT). In: Paper presented at the proceedings of the national aerospace and electronics conference
18. Endsley MR (1995) Toward a theory of situation awareness in dynamic systems. Hum Factors 37:32-64
19. Endsley MR (2000) Theoretical underpinnings of situation awareness: a critical review. In: Endsley MR, Garland DJ (eds) Situation awareness analysis and measurement. Lawrence Erlbaum Associates, Mahwah, pp 3-32
20. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, Khan A, van Walraven C (2004) Adverse events among medical patients after discharge from hospital. Can Med Assoc J 170:345-349
21. Gaba DM, Howard SK, Jump B (1994) Production pressure in the work environment. California anesthesiologists' attitudes and experiences. Anesthesiology 81:488-500
22. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW (2000) Communication breakdown in the outpatient referral process. J Gen Intern Med 15:626-631
23. Henderson BA, Naveiras M, Butler N, Hertzmark E, Ferrufino-Ponce Z (2006) Incidence and causes of ocular surgery cancellations in an ambulatory surgical center. J Cataract Refract Surg 32:95-102
24. Hollnagel E, Woods DD (2005) Joint cognitive systems: foundations of cognitive systems Engineering. Taylor and Francis Group, Boca Raton
25. Ivarsson B, Larsson S, Sjoberg T (2004) Postponed or cancelled heart operations from the patient's perspective. J Nurs Manag 12:28-36
26. Matthews AL, Harvey CM, Schuster RJ, Durso FT (2002) Emergency physician to admitting physician handovers: an exploratory study. In: Human Factors and Ergonomics Society (ed). Proceedings of the human factors and ergonomics society 46th annual meeting. Human Factors and Ergonomics Society, Santa Monica, pp 1511-1515
27. Moore C, Wisnivesky J, Williams S, McGinn T (2003) Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 18:646-651
28. Perry S (2004) Transitions in care: studying safety in emergency department signovers. Focus Patient Saf 7:1-3
29. Prince C, Salas E (2000) Team situation awareness, errors, and crew resource management: research integration for training guidance. In: Endsley MR, Garland DJ (eds) Situation awareness analysis and measurement. Lawrence Erlbaum Associates, Mahwah, NJ pp 325-347
30. Roth EM, Christian CK, Gustafson M, Sheridan TB, Dwyer K, Gandhi TK, Zinner MJ, Dierks MM (2004) Using field observations as a tool for discovery: analyzing cognitive and collaborative demands in the operating room. Cogn Technol Work 6:148-157
31. Salas E, Prince C, Baker DP, Shrestha L (1995) Situation awareness in team performance: implications for measurement and training. Hum Factors 37(1):123-136
32. Schultz K, Carayon P, Hundt AS, Springman SR (2005a) Patient care process and information flow in outpatient surgery. In: Human Factors and Ergonomics Society (ed). Proceedings of the human factors and ergonomics society 49th annual meeting. Human Factors and Ergonomics Society, Santa Monica, pp 1469-1473
33. Schultz K, Carayon P, Hundt AS (2005b) A macroergonomic framework of awareness in transitions of care: application to the preoperative surgery process. In: Carayon P et al (eds) Human factors in organizational design and management-VIII. IEA Press, Santa Monica, pp 311-316
34. Smith K, Hancock PA (1995) Situation awareness is adaptive, externally directed consciousness. Hum Factors 37:137-148
35. Smith PC, Araya-Guerra R, Bublitz C, Parnes B, Dickinson LM, Van Vorst R, Westfall JM, Pace WD (2005) Missing clinical information during primary care visits. J Am Med Assoc 293:565-571
36. Wears RL, Perry SJ, Shapiro M, Beach C, Croskerry P, Behara R (2003) Shift changes among emergency physicians: best of times, worst of times. In: Human Factors and Ergonomics Society (ed). Proceedings of the human factors and ergonomics society 47th annual meeting. Human Factors and Ergonomics Society, Santa Monica, pp 1420-1423
37. Wears RL, Perry SJ, Eisenberg E, Murphy L, Shapiro M, Beach C, Croskerry P, Behara R (2004a) Transitions in care: signovers in the emergency department. In: Human Factors and Ergonomics Society (ed). Proceedings of the human factors and ergonomics society 48th annual meeting. Human Factors and Ergonomics Society, Santa Monica, pp 1625-1628
38. Wears RL, Perry SJ, Eisenberg E, Murphy L, Shapiro M, Beach C, Croskerry P, Behara R (2004b) Conceptual framework for studying shift changes and other transitions in care. In: Human Factors and Ergonomics Society (ed). Proceedings of the human factors and ergonomics society 48th annual meeting. Human Factors and Ergonomics Society, Santa Monica, pp 1615-1619
39. Weick KE, Sutcliffe KM (2001) Managing the unexpected: assuming high performance in an age of complexity. Jossey-Bass, San Francisco