Perspectivas y retos en factores humanos e ingeniería de sistemas en ambientes médicos complejos

Wiener, 1954, The human use of human beings: Cybernetics and society, Da capo press Shojania, 2001 Thomas, 2003, Measuring errors and adverse events in health care, J Gen Intern Med., 18, 61, 10.1046/j.1525-1497.2003.20147.x Reason, 1995, Understanding adverse events: Human factors, Qual Health Care., 4, 80, 10.1136/qshc.4.2.80 Vincent, 2003, Understanding and responding to adverse events, N Engl J Med., 348, 1051, 10.1056/NEJMhpr020760 Kohn, 1999 Pham, 2012, Reducing medical errors and adverse events, Annu Rev Med., 63, 447, 10.1146/annurev-med-061410-121352 Carayon, 2013, Human factors and ergonomics as a patient safety practice, BMJ Qual Saf. Dul, 2012, A strategy for human factors/ergonomics: Developing the discipline and profession, Ergonomics., 55, 377, 10.1080/00140139.2012.661087 Baldwin WC, Sauser B. Modeling the Characteristics of System of Systems. In: Proceedings of SoSE. Albuquerque; 2009:1-6. Blanchard, 1990, 4 Chapanis, 1996 Rouse, 2010, 153 Sittig, 2012, Electronic health records and national patient-safety goals, N Engl J Med., 367, 1854, 10.1056/NEJMsb1205420 Reed, 2016, Adverse Event Triggered Event Reporting for Devices: Report of a Food and Drug Administration--Supported Feasibility Pilot of Automated Adverse Event Reporting, J Clin Eng., 41, 83, 10.1097/JCE.0000000000000151 Utrilla Ramírez AM, Fernández M, Ortega JL, Aguillo IF. Clasificación web de hospitales del mundo: Situación de los hospitales en la red. 2009. Taenzer, 2010, Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers before-and-after concurrence study, J Am Soc Anesthesiol., 112, 282, 10.1097/ALN.0b013e3181ca7a9b Drews, 2013, Human factors in critical care medical environments, Rev Hum Factors Ergon., 8, 103, 10.1177/1557234X13493250 Brilli, 2001, Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model, Crit Care Med., 29, 2007, 10.1097/00003246-200110000-00026 Gershengorn HB, Garland A. Intensivist and Alternative Models of ICU Staffing. Org Crit Care. 2014;18:25-40. RCN Radio. Con plantones, exigen medidas para superar crisis de salud en Antioquia. April 2016 [consultado 3 Abr 2016]. Disponible en: http://www.rcnradio.com/locales/plantones-exigen-medidas-urgentes-superar-crisis-salud-antioqua/ Durso, 2010, Health care, aviation, and ecosystems a socio-natural systems perspective, Curr Dir Psychol Sci., 19, 71, 10.1177/0963721410364728 Harrison, 2007, Unintended consequences of information technologies in health care—an interactive sociotechnical analysis, J Am Med informatics Assoc., 14, 542, 10.1197/jamia.M2384 Berg, 1999, Patient care information systems and health care work: A sociotechnical approach, Int J Med Inform., 55, 87, 10.1016/S1386-5056(99)00011-8 Cresswell, 2013, Organizational issues in the implementation and adoption of health information technology innovations: An interpretative review, Int J Med Inform., 82, e73, 10.1016/j.ijmedinf.2012.10.007 DeLucia, 2009, Performance in nursing, Rev Hum Factors Ergon., 5, 1, 10.1518/155723409X448008 Gurses, 2007, Performance obstacles of intensive care nurses, Nurs Res., 56, 185, 10.1097/01.NNR.0000270028.75112.00 Fackler, 2009, Critical care physician cognitive task analysis: An exploratory study, Crit Care., 13, R33, 10.1186/cc7740 Donchin, 1995, A look into the nature and causes of human errors in the intensive care unit, Crit Care Med., 23, 294, 10.1097/00003246-199502000-00015 Rothschild, 2005, The critical care safety study: The incidence and nature of adverse events and serious medical errors in intensive care, Crit Care Med., 33, 1694, 10.1097/01.CCM.0000171609.91035.BD López, 2010, Funciones del profesional de enfermería en salas de hospitalización de adultos: Tratando de dar cuidado directo, Invest Educ Enferm, 28, 43 Ortiz, 2014, El estrés y su relación con las condiciones de trabajo del personal de enfermería, Invest Educ Enferm., 9 Reader, 2006, Non-technical skills in the intensive care unit, Br J Anaesth., 96, 551, 10.1093/bja/ael067 Gordon, 2012, Non-technical skills training to enhance patient safety: A systematic review, Med Educ., 46, 1042, 10.1111/j.1365-2923.2012.04343.x Roter, 2000, The enduring and evolving nature of the patient--physician relationship, Patient Educ Couns., 39, 5, 10.1016/S0738-3991(99)00086-5 Koutantji, 2005, The patient's role in patient safety: Engaging patients, their representatives, and health professionals, Clin Risk., 11, 99 Tresolini, 1994, Health professions education and relationship-centered care, San Fr Pew Heal Prof Comm. Parush, 2011, Communication and team situation awareness in the OR: Implications for augmentative information display, J Biomed Inform., 44, 477, 10.1016/j.jbi.2010.04.002 Teng, 2010, Interactive effects of nurse-experienced time pressure and burnout on patient safety: A cross-sectional survey, Int J Nurs Stud., 47, 1442, 10.1016/j.ijnurstu.2010.04.005 Vincent, 2002, Patient safety: What about the patient?, Qual Saf Heal Care, 11, 76, 10.1136/qhc.11.1.76 Benn, 2009, Feedback from incident reporting: Information and action to improve patient safety, Qual Saf Heal Care., 18, 11, 10.1136/qshc.2007.024166 Rodríguez, 2012, Algunas causas de la crisis financiera en el sistema de salud en Colombia en el 2009 (Some Causes of the Financial Crisis in the Colombian Health System in 2009), Econografos., 30, 24 Echeverry-López, 2015, Protestas sociales por la salud en Colombia: La lucha por el derecho fundamental a la salud, 1994-2010 Public demonstrations for health as a fundamental human right in Colombia: 1994-2010, Cad Saúde Pública., 31, 354, 10.1590/0102-311X00030714 Patiño, 2013, El sistema de salud de Colombia: Crisis sin precedentes, Rev Colomb Cir., 28, 259 Díaz F, Liliana M, Chaves Bello JP. La Calidad de Atención En Salud, Reto O Sofisma. Bogotá: Universidad Militar Nueva Granada; 2013. Parra, 2012, Eventos adversos derivados del cuidado de enfermería: Flebitis, úlceras por presión y caídas, Enferm Glob., 11, 159, 10.6018/eglobal.11.4.150551 Salmon, 2006, Situation awareness measurement: A review of applicability for C4i environments, Appl Ergon., 37, 225, 10.1016/j.apergo.2005.02.001 Smith, 1995, Situation awareness is adaptive, externally directed consciousness, J Hum Factors Ergon Soc, 37, 137, 10.1518/001872095779049444 Koch, 2012, Intensive care unit nurses’ information needs and recommendations for integrated displays to improve nurses’ situation awareness, J Am Med Informatics Assoc., 19, 583, 10.1136/amiajnl-2011-000678 Sarter, 1991, Situation awareness: A critical but ill-defined phenomenon, Int J Aviat Psychol., 1, 45, 10.1207/s15327108ijap0101_4 Endsley, 2013, Situation awareness, Oxford Handb Cogn Eng., 8, 8 Arora, 2012, Safety skills training for surgeons: A half-day intervention improves knowledge, attitudes and awareness of patient safety, Surgery., 152, 26, 10.1016/j.surg.2012.02.006 Safer Healthcare. Situational Awareness in Healthcare. August 2015 [conaultado 5 Ago 2015]. http://www.saferhealthcare.com/high-reliability-topics/reducing-medical-errors/ Endsley, 1995, Toward a theory of situation awareness in dynamic systems, J Hum Factors Ergon Soc, 37, 32, 10.1518/001872095779049543 Parush, 2011 Ministerio de la Protección Social de Colombia. Lineamientos para la implementación de la Política de Seguridad del Paciente. 2008. Holden, 2011, Lean thinking in emergency departments: A critical review, Ann Emerg Med., 57, 265, 10.1016/j.annemergmed.2010.08.001 De Savigny, 2009 Magnussen, 2009 Haug, 1994, Elderly patients, caregivers, and physicians: Theory and research on health care triads, J Health Soc Behav., 1, 10.2307/2137331 Carayon, 2006, Work system design for patient safety: The SEIPS model, Qual Saf Heal Care., 15, i50, 10.1136/qshc.2005.015842 Holden, 2013, SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients, Ergonomics., 56, 1669, 10.1080/00140139.2013.838643 Alvarado-Cabrero, 2012, Redefinición de la productividad y de la calidad de los diagnósticos del patólogo en un hospital de oncología, GAMO., 11, 145 Carayon, 2009, Patient safety, Inf Knowl Syst Manag., 8, 23 Gurses, 2009, Impact of performance obstacles on intensive care nurses’ workload, perceived quality and safety of care, and quality of working life, Health Serv Res., 44, 422, 10.1111/j.1475-6773.2008.00934.x Karsh, 2006, A human factors engineering paradigm for patient safety: Designing to support the performance of the healthcare professional, Qual Saf Heal Care., 15, i59, 10.1136/qshc.2005.015974 Or, 2009, A systematic review of patient acceptance of consumer health information technology, J Am Med Informatics Assoc., 16, 550, 10.1197/jamia.M2888 DeBourgh, 2012, Patient safety manifesto: A professional imperative for prelicensure nursing education, J Prof Nurs., 28, 110, 10.1016/j.profnurs.2011.05.001 Holden, 2011, A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life, BMJ Qual Saf., 20, 15, 10.1136/bmjqs.2008.028381 Vincent C. Patient Safety. Vol 1st ed. (BMJ, ed.). John Wiley & Sons; 2014. http://www.england.nhs.uk/ourwork/patientsafety/ Vincent, 2004, Systems approaches to surgical quality and safety: From concept to measurement, Ann Surg., 239, 475, 10.1097/01.sla.0000118753.22830.41 Rasmussen, 1997, Risk management in a dynamic society: A modelling problem, Saf Sci., 27, 183, 10.1016/S0925-7535(97)00052-0 Cook, 2005, Going solid: A model of system dynamics and consequences for patient safety, Qual Saf Heal Care., 14, 130, 10.1136/qshc.2003.009530 McDonnell, 2010, Electronic health record usability: Vendor practices and perspectives, AHRQ Publ., 09, 10 Association for the Advancement of Medical Instrumentation, others. ANSI/AAMI HE75: 2009. Hum Factors Eng Design Med Devices. 2009. Sriram RD, Fenves SJ. Manufacturing metrology and standards for the Health Care Enterprise Program Summary. Gaithesburg: National Institute of Standards and Technology, NISTIR; 2008:115. Weinger MB, Wiklund ME, Gardner-Bonneau DJ. Handbook of human factors in medical device design. Boca Raton: CRC Press; 2010. http://www.crcnetbase.com/doi/abs/10.1201/b10439-16 Koppel, 2005, Role of computerized physician order entry systems in facilitating medication errors, JAMA., 293, 1197, 10.1001/jama.293.10.1197 Beasley, 2011, Information chaos in primary care: Implications for physician performance and patient safety, J Am Board Fam Med., 24, 745, 10.3122/jabfm.2011.06.100255 Carayon, 2010, Human factors in patient safety as an innovation, Appl Ergon., 41, 657, 10.1016/j.apergo.2009.12.011 Peute, 2013, A framework for reporting on human factor/usability studies of health information technologies, Stud Heal Technol Inf., 194, 54 Beuscart-Zéphir, 2010, Human factors engineering for healthcare IT clinical applications, Int J Med Inform., 79, 223, 10.1016/j.ijmedinf.2010.01.010 Ibeas, 2009 Guerrero, 2011, Sistema de salud de Colombia, Salud Púb Méx., 53, s144 Ministerio de la Protección Social de Colombia. Política Nacional de Prestacion de Servicios de Salud. Bogotá: Ministerio de la Proteccion Social; 2005. Cardona Lopez MM, Ramírez Vásquez MP, Castrillon Cadavid VM. Las Entidades Promotoras de Salud Y El Sistema General de Seguridad Social En Salud. Medellin: CES; 2014. ICONTEC. Acreditación en Salud. April 2016 [consultado 15 Abr 2016]. http://www.icontec.org/Ser/EvCon/Paginas/As.aspx/ INVIMA. ABC De Tecnovigilancia. Bogotá; 2016. https://www.invima.gov.co/images/pdf/tecnovigilancia/ABC Tecnovigilancia INVIMA.pdf Woolf, 2008, The meaning of translational research and why it matters, JAMA., 299, 211, 10.1001/jama.2007.26 Henriksen K, Dayton E, Keyes MA, Carayon P, Hughes R. Understanding adverse events: a human factors framework. In: RG H, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD 20850: Agency for Healthcare Research and Quality (US); 2008:1403. Kannampallil, 2011, Considering complexity in healthcare systems, J Biomed Inform., 44, 943, 10.1016/j.jbi.2011.06.006 Halm, 2003, Frequency and impact of active clinical issues and new impairments on hospital discharge in patients with hip fracture, Arch Intern Med., 163, 107, 10.1001/archinte.163.1.107 O’Mahony, 2007, Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay, J Gen Intern Med., 22, 1073, 10.1007/s11606-007-0225-1 Staggers, 2009, The content and context of change of shift report on medical and surgical units, J Nurs Adm., 39, 393, 10.1097/NNA.0b013e3181b3b63a Gandhi, 2005, Fumbled handoffs: One dropped ball after another, Ann Intern Med., 142, 352, 10.7326/0003-4819-142-5-200503010-00010 Nast, 2005, Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit, J Thorac Cardiovasc Surg., 130, 1137, 10.1016/j.jtcvs.2005.06.003 Perry SJ, Wears RL, Patterson ES. High-hanging fruit: improving transitions in health care. In: Advances in Patient Safety: New Directions and Alternative Approaches. Rockville MD 20850: Agency for Healthcare Research and Quality (US); 2008:25. Carroll, 2012, The ins and outs of change of shift handoffs between nurses: A communication challenge, BMJ Qual Saf., 21, 586, 10.1136/bmjqs-2011-000614 Collins, 2011, Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: A systematic review, J Biomed Inform., 44, 704, 10.1016/j.jbi.2011.01.013 Herring, 2011, Implementation of a considerative checklist to improve productivity and team working on medical ward rounds, Clin Gov An Int J., 16, 129, 10.1108/14777271111124482 Consultants, 2005, JCAHO to look closely at patient handoffs: Communication lapses will be key focus, Healthcare Benchmarks Qual Improv., 12, 143 Dodek, 2003, Explicit approach to rounds in an ICU improves communication and satisfaction of providers, Intensive Care Med., 29, 1584, 10.1007/s00134-003-1815-y Han, 2005, Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system, Pediatrics., 116, 1506, 10.1542/peds.2005-1287 Kaye, 2000, Medical device use-safety: Incorporating human factors engineering into risk management, Food Drug Adm. White, 1998, Improving patient care by reporting problems with medical devices, J Toxicol Clin Toxicol., 36, 641, 10.3109/15563659809028066 Chulay M, Burns SM. AACN essentials of critical care nursing: Pocket handbook. Nueva York: McGraw-Hill Medical; Londres: McGraw-Hill [distributor]; 2010. Drews, 2014, Evaluation of a configural vital signs display for intensive care unit nurses, Hum Factors J Hum Factors Ergon Soc., 56, 569, 10.1177/0018720813499367 Wong, 2003, Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system, Crit Care Med., 31, 2488, 10.1097/01.CCM.0000089637.53301.EF Sward, 2008, Reasons for declining computerized insulin protocol recommendations: Application of a framework, J Biomed Inform., 41, 488, 10.1016/j.jbi.2008.04.002 Block, 1996, Auditory alarms during anesthesia monitoring with an integrated monitoring system, Int J Clin Monit Comput., 13, 81, 10.1007/BF02915842 Drews FA. The frequency and impact of task interruptions in the ICU. In: Proceedings of the Human Factors and Ergonomics Society 51st Annual Meeting. Vol 51. Baltimore; 2007:683-686. Obradovich, 1996, Special section: Users as designers: How people cope with poor HCI design in computer-based medical devices, Hum Factors J Hum Factors Ergon Soc., 38, 574, 10.1518/001872096778827251 Sucher, 2008, Computerized clinical decision support: A technology to implement and validate evidence based guidelines, J Trauma Acute Care Surg., 64, 520, 10.1097/TA.0b013e3181601812 Mador, 2009, The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: A review of the literature, Int J Med Inform., 78, 435, 10.1016/j.ijmedinf.2009.01.002 McDonald, 2013, Patient safety strategies targeted at diagnostic errors: A systematic review, Ann Intern Med., 158, 381, 10.7326/0003-4819-158-5-201303051-00004 Weaver, 2013, Promoting a culture of safety as a patient safety strategy: A systematic review, Ann Intern Med., 158, 369, 10.7326/0003-4819-158-5-201303051-00002 Itoh, 2008, A national survey on healthcare safety culture in Japan: Analysis of 20,000 staff responses from 84 hospitals, Management., 4, 22 Sexton, 2011, Assessing and improving safety climate in a large cohort of intensive care units, Crit Care Med., 39, 934, 10.1097/CCM.0b013e318206d26c Fontaine, 2001, Designing humanistic critical care environments, Crit Care Nurs Q., 24, 21, 10.1097/00002727-200111000-00003 Alvarado C. The physical environment in health care. In: Handbook of Human Factors and Ergonomics in Healthcare. Boca Raton: CRC Press; 2007:287-307. Horsburgh, 1995, Healing by design, N Engl J Med., 333, 735, 10.1056/NEJM199509143331117 Pronovost, 2008, Improving patient safety in intensive care units in Michigan, J Crit Care., 23, 207, 10.1016/j.jcrc.2007.09.002 Brown, 2006, Impacting patient outcomes through design: Acuity adaptable care/universal room design, Crit Care Nurs Q., 29, 326, 10.1097/00002727-200610000-00006 Rashid, 2006, A Decade of adult intensive care unit design: A study of the physical design features of the best-practice examples, Crit Care Nurs Q., 29, 282, 10.1097/00002727-200610000-00003 Hunink, 2014 Asociación Colombiana de Hospitales y Clínicas. Instituciones prestadoras de Salud a nivel nacional. Septiembre 2014 [consultado 17 Sep 2015]. http://www.achc.org.co/investigaciones.php?idcat=302 Patel, 2012, ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography, J Am Coll Cardiol., 59, 1995, 10.1016/j.jacc.2012.03.003 Costa, 2016, Organizing Critical Care for the 21st century, JAMA., 315, 751, 10.1001/jama.2016.0974 Brennan, 1991, Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard medical practice study I, N Engl J Med., 324, 370, 10.1056/NEJM199102073240604 Hendrick, 2005 Cabieses, 2011, La investigación traslacional y su aporte para la toma de decisiones en políticas de salud, Rev Peru Med Exp Salud Pública., 28, 288, 10.1590/S1726-46342011000200017 ACSNI. Third report: Organizing for safety. ACSNI Study Group on Human Factors. Londres: HMSO; 1993.