Creating a Culture of Continuous Learning: Solutions for Patient Safety
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Safety; learning; resilience; safety culture↗
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Future needs for biomedical transducers
In summary there are three major classes of transducer improvements required: improvements in existing transducers, needs for unexploited physical science phenomena in transducer design, and needs for unutilized physiological phenomena in transducer design. During the next decade, increasing emphasis will be placed on noninvasive measurement in all of these areas. Patient safety, patient comfort, and the need for efficient utilization of the time of both patient and physician requires that noninvasive methods of monitoring be developed.
Wooten, F. T.↗
A New Cure for Medical Errors
In May 2000, senior officials of the U.S. Department of Veterans Affairs (VA) and NASA signed an agreement that would commit the two agencies to create the Patient Safety Reporting System (PSRS) to report: events or situations that could have resulted in accident, injury, or illness, but did not, either by chance or through timely intervention (close-calls); unexpected serious occurrences that involved a patient or employee's death, physical injury, or psychological injury; lessens learned; and safety ideas. The VA provided NASA with funding for the initial development of the new system, which automatically removes all personal names, facility names and locations, and other potentially identifying information before entering reports into its database. Designed to complement the VA's current internal reporting systems, the PSRS is modeled after NASA's Aviation Safety Reporting System, which was established in 1975 under a Memorandum of Agreement between the Federal Aviation Administration and NASA and began operation in 1976.
Source record↗
Design of a specialized computer for on-line monitoring of cardiac stroke volume
The design of a specialized analog computer for on-line determination of cardiac stroke volume by means of a modified version of the pressure pulse contour method is presented. The design consists of an analog circuit for computation and a timing circuit for detecting necessary events on the pressure waveform. Readouts of arterial pressures, systolic duration, heart rate, percent change in stroke volume, and percent change in cardiac output are provided for monitoring cardiac patients. Laboratory results showed that computational accuracy was within 3 percent, while animal experiments verified the operational capability of the computer. Patient safety considerations are also discussed.
Webb, J. A., Jr.↗
Pharmacy in a New Frontier - The First Five Years at the Johnson Space Center Pharmacy
A poster entitled "Space Medicine - A New Role for Clinical Pharmacists" was presented in December 2001 highlighting an up-and-coming role for pharmacists at the Johnson Space Center (JSC) in Houston, Texas. Since that time, the operational need for the pharmacy profession has expanded with the administration s decision to open a pharmacy on site at JSC to complement the care provided by the Flight Medicine and Occupational Medicine Clinics. The JSC Pharmacy is a hybrid of traditional retail and hospital pharmacy and is compliant with the ambulatory care standards set forth by the Joint Commission. The primary charge for the pharmacy is to provide medication management for JSC. In addition to providing ambulatory care for both clinics, the pharmacists also practice space medicine. A pharmacist had been involved in the packing of both the Space Shuttle and International Space Station Medical Kits before the JSC Pharmacy was established; however, the role of the pharmacist in packing medical kits has grown. The pharmacists are now full members of the operations team providing consultation for new drug delivery systems, regulations, and patient safety issues. As the space crews become more international, so does the drug information provided by the pharmacists. This presentation will review the journey of the JSC Pharmacy as it celebrated its five year anniversary in April of 2008. The implementation of the pharmacy, challenges to the incorporation of the pharmacy into an existing health-care system, and the current responsibilities of a pharmacist at the Johnson Space Center will be discussed.
Bayuse, Tina↗
3D Endoscope to Boost Safety, Cut Cost of Surgery
Researchers at the Jet Propulsion Laboratory worked with the brain surgeon who directs the Skull Base Institute in Los Angeles to create the first endoscope fit for brain surgery and capable of producing 3D video images. It is also the first to be able to steer its lens back and forth. These improvements to visibility are expected to improve safety, speeding patient recovery and reducing medical costs.
Source record↗
Hydrostatic Hyperbaric Chamber Ventilation System
The hydrostatic hyperbaric chamber (HHC) represents the merger of several technologies in development for NASA aerospace applications, harnessed to directly benefit global health. NASA has significant experience developing composite hyperbaric chambers for a variety of applications. NASA also has researched the application of water-filled vessels to increase tolerance of acceleration forces. The combination of these two applications has resulted in the hydrostatic chamber, which has been conceived as a safe, affordable means of making hyperbaric oxygen therapy (HBOT) available in the developing world for the treatment of a variety of medical conditions. Specifically, HBOT is highly-desired as a possibly curative treatment for Buruli Ulcer, an infectious condition that afflicts children in sub-Saharan Africa. HBOT is simply too expensive and too dangerous to implement in the developing world using standard equipment. The HHC technology changes the paradigm. The HHC differs from standard hyperbaric chambers in that the majority of its volume is filled with water which is pressurized by oxygen being supplied in the portion of the chamber containing the patient s head. This greatly reduces the amount of oxygen required to sustain a hyperbaric atmosphere, thereby making the system more safe and economical to operate. An effort was taken to develop an HHC system to apply HBOT to children that is simple and robust enough to support transport, assembly, maintenance and operation in developing countries. This paper details the concept for an HHC ventilation and pressurization system to provide controlled pressurization and adequate washout of carbon dioxide while the subject is enclosed in the confined space during the administration of the medical treatment. The concept took into consideration operational complexity, safety to the patient and operating personnel, and physiological considerations. The simple schematic, comprised of easily acquired commercial hardware, supports sustainability.
Sarguisingh, Miriam J.↗
Hydrostatic Hyperbaric Chamber Ventilation System
The hydrostatic hyperbaric chamber (HHC) represents the merger of several technologies in development for NASA aerospace applications, harnessed to directly benefit global health. NASA has significant experience developing composite hyperbaric chambers for a variety of applications, including the treatment of medical conditions. NASA also has researched the application of water-filled vessels to increase tolerance of acceleration forces. The combination of these two applications has resulted in the hydrostatic chamber, which has been conceived as a safe, affordable means of making hyperbaric oxygen therapy available in the developing world for the treatment of a variety of medical conditions. Specifically, hyperbaric oxygen therapy is highly-desired as a possibly curative treatment for Buruli Ulcer, an infectious condition that afflicts children in sub-Saharan Africa. Hyperbaric oxygen therapy is simply too expensive and too dangerous to implement in the developing world using standard equipment. The hydrostatic hyperbaric chamber technology changes the paradigm. The HHC differs from standard hyperbaric chambers in that the majority of its volume is filled with water which is pressurized by oxygen being supplied in the portion of the chamber containing the patient s head. This greatly reduces the amount of oxygen required to sustain a hyperbaric atmosphere, thereby making the system more safe and economical to operate. An effort was taken to develop an HHC system to apply HBOT to children that is simple and robust enough to support transport, assembly, maintenance and operation in developing countries. This paper details the concept for an HHC ventilation and pressurization system that will provide controlled pressurization of the system, and provide adequate washout of carbon dioxide while the subject is enclosed in the confined space during the administration of the medical treatment. The concept took into consideration operational complexity, safety to the patient and operating personnel, and physiological considerations. The simple schematic, comprised of easily acquired commercial hardware, supports sustainability.
Sargusingh, Miriam M.↗
Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses
A hospital-based survey on shift work, sleep, and accidents was carried out among 635 Massachusetts nurses. In comparison to nurses who worked only day/evening shifts, rotators had more sleep/wake cycle disruption and nodded off more at work. Rotators had twice the odds of nodding off while driving to or from work and twice the odds of a reported accident or error related to sleepiness. Application of circadian principles to the design of hospital work schedules may result in improved health and safety for nurses and patients.
Non-NASA Center↗
Human behavioral research in space: quandaries for research subjects and researchers
With the advent of long-duration spaceflight on board the International Space Station (ISS) and possible future missions beyond low Earth orbit (LEO) such as Mars, it is critical that those at NASA have a realistic assessment of the challenges that will face individuals on long-duration missions so that they can develop preventive and real-time countermeasures to behavioral health issues. While space travellers are very interested in having countermeasures to the deleterious effects of space missions, they have a powerful disincentive to participate in this research if they feel it could in any way negatively affect their flight status. The behavioral issues of isolation and confinement for extended-duration space missions are reviewed. Areas of basic and clinical behavioral research are listed. And the classical clinical model for research is not considered appropriate for the current configuration of the space program. The use of analogue environments and advanced statistical analysis are suggested as ways to address the limited spaceflight research opportunities. The challenge of research subject or patient confidentiality vs. mission safety and issues of personal flight status are addressed.
Review, Tutorial↗
NASA: Biomedical applications team
The status of projects involving the adaptation of NASA technologies for medical purposes is reviewed. Devices for the measurement of joint deformation of arthritic hands, the development of an artificial pancreas, provision of an auditory signal to avert epileptic seizures, are described along with the control of medication levels, a compressed air tank to supply power for field dentistry, and an electroencephalogram monitor. The use of the Lixiscope as a portable fluoroscope, thermal laminates for hand and foot warmers for patients with Raynaud's syndrome, and the use of absorptive coatings for instruments for controlling medication levels are described. The applicability of occupation health and safety practices to industry, computerized patient scheduling, impregnation of the common facial tissue with an agent for killing respiratory viruses, commercial applications of anthropometric data, and multispectral image analysis of the skin as a diagnostic tool are reviewed.
Source record↗
Human Systems Integration: Managing Risk in Anesthesia
The practice of anesthesia relies on clinicians’ ability to safely manage increasingly complex equipment. Devices such as ventilators, drug infusion pumps, and physiologic monitors use sophisticated algorithms to deliver care, but most clinicians are only trained to manage automated systems during normal operation. Few if any receive training on how to manage system failures. Although manufacturers are required to consult with human factors engineers as part of the equipment design process, most pieces of equipment are ultimately brought to market without extensive input from clinicians. Systems in the operating room can be as simple as an oxygen tank, or as complex as a multi-institutional healthcare organization. Humans are also a complex system, and play a critical role in the domains of operations, design, fabrication, maintenance, repair, and ultimately, dismantling and closeout. HSI seeks to provide a means for advocating the human side of the system. Human Systems Integration (HSI) is the cross disciplinary process used as part of the Systems Engineering process to reduce risk in systems. HSI professionals consider the human, hardware, and software elements of system design to optimize system performance and improve safety. HSI professionals work in domains of study that include training, management, human factors engineering, safety, and occupational health, among others. This article discusses the role of systems in the practice of anesthesia, and how consideration of the human during all phases of the system life cycle helps manage risks and promote a better patient outcome.
Human Factors↗
Detectors Ensure Function, Safety of Aircraft Wiring
Pedro Medelius waited patiently in his lab at Kennedy Space Center. He had just received word that a colleague was bringing over a cable from a Space Shuttle solid rocket booster to test Medelius new invention. Medelius was calm until his colleague arrived, with about 30 other people. "Talk about testing under pressure," says Medelius. "There were people there from the Navy, the Air Force, and the Federal Aviation Administration." After the group s arrival, Medelius took a deep breath and connected his Standing Wave Reflectometer (SWR) to the cable. He wiggled the cable around, and the display showed a fault (a short or open circuit in wire) about an inch and a half inside the connector on the cable. His colleague questioned the results, because he had already checked that area on the cable. Medelius used the SWR to check again but got the same result. "That is when we took the cable apart and looked inside," Medelius says. "Lo and behold, that was exactly where the fault was." The impetus for Medelius new wire inspection technology came about in 1999 when one of the space shuttles lost power due to a fault somewhere in its more than 200 miles of electrical wiring. "The backup circuit was activated and prevented a major dysfunction, but nevertheless, there was a problem with the wiring," Medelius describes. Even though technicians used a device called a multimeter to measure the electrical current to find which wire had a fault, it could not pinpoint exactly where on the wire the fault was located. For that, technicians had to visually inspect the wire. "Sometimes they would have to remove the whole wire assembly and visually inspect every single wire. It was a very tedious operation because the wires are behind cabinets. They go all over the place in the shuttle," says Medelius. "NASA needed an instrument capable of telling them exactly where the faults were occurring." To meet NASA s needs for a highly precise device to inspect electrical power bundles, wires, and connectors, Medelius devised the SWR. "It came down to what was affected when a wire is short circuited or opened," he says. "We worked out a few equations based on physical principles." The SWR proved very sensitive, and the technology was patented.
Source record↗
Neurogenic orthostatic hypotension: a double-blind, placebo-controlled study with midodrine
PURPOSE: To investigate the efficacy and safety of midodrine for treatment of patients with orthostatic hypotension due to autonomic failure. PATIENTS: Ninety-seven patients with orthostatic hypotension were randomized in a 4-week, double-blinded, placebo-controlled study with a 1-week placebo run-in period. Patients ranged in age from 22 to 86 years (mean: 61 years). METHODS: After a 1-week run-in phase, either placebo or midodrine at a dose of 2.5 mg, 5 mg, or 10 mg was administered three times a day for 4 weeks. Both the placebo group and the 2.5-mg midodrine group received constant doses throughout the double-blind phase. The patients receiving 5 mg or 10 mg of midodrine were given doses that were increased at weekly intervals by 2.5-mg increments until the designated dose was reached. Efficacy evaluations were based on an improvement at 1-hour postdose in standing systolic blood pressure and in symptoms of orthostatic hypotension (syncope, dizziness/lightheadedness, weakness/fatigue, and low energy level). RESULTS: Midodrine (10 mg) increased standing systolic blood pressure by 22 mm Hg (28%, p < 0.001 versus placebo). Midodrine improved (p < 0.05) the following symptoms of orthostatic hypotension compared to placebo: dizziness/lightheadedness, weakness/fatigue, syncope, low energy level, impaired ability to stand, and feelings of depression. The overall side effects were mainly mild to moderate. One or more side effects were reported by 22% of the placebo group compared with 27% of the midodrine-treated group. Scalp pruritus/tingling, which was reported by 10 of 74 (13.5%) of the midodrine-treated patients, was most frequent. Other reported side effects included supine hypertension (8%) and feelings of urinary urgency (4%). CONCLUSION: We conclude that midodrine is an effective and well-tolerated treatment for moderate-to-severe orthostatic hypotension associated with autonomic failure.
NASA Discipline Number 14-10↗
Medical-Information-Management System
Medical Information Management System (MIMS) computer program interactive, general-purpose software system for storage and retrieval of information. Offers immediate assistance where manipulation of large data bases required. User quickly and efficiently extracts, displays, and analyzes data. Used in management of medical data and handling all aspects of data related to care of patients. Other applications include management of data on occupational safety in public and private sectors, handling judicial information, systemizing purchasing and procurement systems, and analyses of cost structures of organizations. Written in Microsoft FORTRAN 77.
Alterescu, Sidney↗
Safety in the operating theatre--part 1: interpersonal relationships and team performance
The authors examine the application of interpersonal human factors training on operating room (OR) personnel. Mortality studies of OR deaths and critical incident studies of anesthesia are examined to determine the role of human error in OR incidents. Theoretical models of system vulnerability to accidents are presented with emphasis on a systems approach to OR performance. Input, process, and outcome factors are discussed in detail.
Non-NASA Center↗
Crew Management Processes Revitalize Patient Care
In 2005, two physicians, former NASA astronauts, created LifeWings Partners LLC in Memphis, Tennessee and began using Crew Resource Management (CRM) techniques developed at Ames Research Center in the 1970s to help improve safety and efficiency at hospitals. According to the company, when hospitals follow LifeWings? training, they can see major improvements in a number of areas, including efficiency, employee satisfaction, operating room turnaround, patient advocacy, and overall patient outcomes. LifeWings has brought its CRM training to over 90 health care organizations and annual sales have remained close to $3 million since 2007.
Source record↗
Human factors and safety in emergency medicine
A model based on an input process and outcome conceptualisation is suggested to address safety-relevant factors in emergency medicine. As shown in other dynamic and demanding environments, human factors play a decisive role in attaining high quality service. Attitudes held by health-care providers, organisational shells and work-cultural parameters determine communication, conflict resolution and workload distribution within and between teams. These factors should be taken into account to improve outcomes such as operational integrity, job satisfaction and morale.
Non-NASA Center↗