Patient Handoffs: A Cognitive
Systems Engineering Perspective
November 11, 2011
What is cognitive systems engineering?
Human Factors (‘50):
interdisciplinary human-centered
approach to addressing design
challenges
Cognitive Systems Engineering (‘80):
engineering a system of human and
machine agents performing cognitive
tasks in a domain
Cognitive Systems Engineering is...
Coping with Complexity
In challenging:
With experts:
Supported by:
•
•
•
•
• expertise
• knowledge
• strategies
• artifacts
• other agents
situations
scenarios
tasks
domains
Cognitive Triad
…In The Era of Complexity
New
Communication
Formats
Augmented Cognitive Capacity
Integrated
Capabilities
How Did NASA do Handoffs?
NASA: Handoffs Help to Recognize
Unexpected Events
…making sure they correctly interpret nominal
situations as being nominal, and recognize early in
the game off-nominal signatures …The handover's
critical … in how they have correctly detected and
communicated the situational status*
*Tandi Bagian, e-mail, January 31, 2000
6
Potential Lessons for Patient Handoffs
Communicate whether an event is expected or
unexpected
Include degree of diagnostic uncertainty
Provide evidence for diagnostic judgments to
allow errors to be detected
Be receptive to having reasoning challenged
7
NASA: Handoffs are Given to Someone
Who Already Knows a Lot
Along with having a base of knowledge [from
working the day before], the incoming folks likely
have seen the anomaly/fault log, the events that
[NASA] is currently tracking, have been listening
to the loops or watching [NASA TV]*
*Tandi Bagian, e-mail, January 31, 2000
8
Potential Lessons for Patient Handoffs
Distinguish between novel and ‘handback’
information
For handback information: Emphasize what has
happened since the person was last directly
responsible and who will do pending actions
Expect active engagement from person accepting
handoff
9
NASA: Handoffs are ‘Bottom Line’
and Details on Demand
Folks are mentored to
understand that handovers
are to be efficient, pass along
what needs to be
understood, verify correct
situational awareness …it's a
real skill that comes hard to
some folks who would
naturally try to provide details
and descriptions, rather than
primarily the bottom line.*
*Tandi Bagian, e-mail, January 31, 2000
10
Potential Lessons for Patient Handoffs
Emphasize synthesis and interpretation
Use ‘on the job’ coaching to minimize details and
descriptions
Minimize social elements during handoff
Triage ‘most important first’ in case handoff is cut
short
11
Summary of CSE Perspective on
Handoff Opportunities
Efficiency could be increased by:
• Reducing handback information
• Coaching on ‘bottom line’ interpretation and
synthesis skill
• Providing details on demand
System resilience could be increased with:
• Faster responses to unexpected events
• Detecting erroneous situation assessments
• Clarifying responsibility for pending actions
12
Thank you for your attention
Partial funding provided by the 2010-2011 Hospira
Research Grant of the National Patient Safety Foundation