Lukasz Mazur | University of North Carolina at Chapel Hill (original) (raw)

Papers by Lukasz Mazur

Advances in radiation oncology

There is a need to better prepare radiation therapy (RT) providers to safely operate within the h... more There is a need to better prepare radiation therapy (RT) providers to safely operate within the health information technology (IT) sociotechnical system. Simulation-based training has been preemptively used to yield meaningful improvements during providers' interactions with health IT, including RT settings. Therefore, on the basis of the available literature and our experience, we propose principles for the effective design and use of simulated scenarios and describe a conceptual framework for a debriefing approach to foster successful training that is focused on safety mindfulness during RT professionals' interactions with health IT.

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DESALINATION AND WATER TREATMENT

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Suboptimal usability within electronic health records (EHRs) can pose risks for patient safety. T... more Suboptimal usability within electronic health records (EHRs) can pose risks for patient safety. This study uses data collected in a simulated environment in which providers interacted with ‘current’ and ‘enhanced’ Epic EHR interfaces to manage patients’ test results and missed appointments. Interactions were quantified and categorized by high or low burden in terms of displayed behavioral and physiological data. Using recorded video data, providers’ workflow and performance was analyzed. Suboptimal performance was found to be associated with high burden levels.

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting

Usability and cognitive workload (CWL) are multidimensional constructs that describe user experie... more Usability and cognitive workload (CWL) are multidimensional constructs that describe user experience, predict performance, and inform system design. The relationship between the subjective measures of these constructs has not been adequately explored, especially in healthcare delivery settings where suboptimal usability of electronic health records and CWL of healthcare professionals are among the major contributing factors to medical errors. This study quantifies the perceived usability of a dosimetry quality assurance (QA) checklist and the perceived CWL of dosimetrists in radiation oncology clinical settings of an academic medical center and investigates the association between perceived usability and perceived CWL. Findings suggest that our institutional dosimetry QA checklist has suboptimal usability, but the associated CWL is acceptable. Further, the correlation analysis reveals that perceived usability and perceived CWL are non-overlapping constructs and may be jointly employ...

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Journal of the American College of Surgeons

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Frontiers in Oncology

Purpose/Objectives: Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT... more Purpose/Objectives: Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) may be considered “high risk” due to the high doses per fraction. We analyzed CyberKnife™ (CK) SRS and SBRT-related incidents that were prospectively reported to our in-house incident learning system (ILS) in order to identify severity, contributing factors, and common error pathways. Material and Methods: From 2012 to 2019, 221 reported incidents related to the 4,569 CK fractions delivered (5.8%) were prospectively analyzed by our multi-professional Quality and Safety Committee with regard to severity, contributing factors, as well as the location where the incident occurred (tripped), where it was discovered (caught), and the safety barriers that were traversed (crossed) on the CK process map. Based on the particular step in the process map that incidents tripped, we categorized incidents into general error pathways. Results: There were 205 severity grade 1–2 (did not reach patient or no clinical impact), 11 grade 3 (clinical impact unlikely), 5 grade 4 (altered the intended treatment), and 0 grade 5–6 (life-threatening or death) incidents, with human performance being the most common contributing factor (79% of incidents). Incidents most commonly tripped near the time when the practitioner requested CK simulation (e.g., pre-CK simulation fiducial marker placement) and most commonly caught during the physics pre-treatment checklist. The four general error pathways included pre-authorization, billing, and scheduling issues (n= 119); plan quality (n= 30); administration of IV contrast during simulation or pre-medications during treatment (n= 22); and image guidance (n= 12). Conclusion: Most CK incidents led to little or no patient harm and most were related to billing and scheduling issues. Suboptimal human performance appeared to be the most common contributing factor to CK incidents. Additional study is warranted to develop and share best practices to reduce incidents to further improve patient safety.

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Engineering Management Journal

Abstract Despite positive reports about lean approaches to spearhead quality and patient safety i... more Abstract Despite positive reports about lean approaches to spearhead quality and patient safety improvement efforts, it is still difficult to determine if healthcare employees have transformed into effective lean thinkers. Lean thinking refers to individuals who operate with thoughtful reflection on organizational issues, are committed to continuous improvement efforts, and demonstrate the willingness to lead change. The objective of this theory building research is to contribute a survey instrument and conceptual model to measure individual transformation to lean thinking. Our learnings from the case study suggest that healthcare a professional’s transition to lean thinking via a complex combination of awareness issues at both the unit and individual levels, and both levels should be considered when moving individuals toward readiness and through a personal transformation to lean thinking.

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Practical Radiation Oncology

While the vast majority of radiation treatments (RT) are effective and carried out without result... more While the vast majority of radiation treatments (RT) are effective and carried out without resulting in patient harm, quality and safety events of varying clinical significance do occur. Ensuring safety within RT is of paramount importance. To further support and augment patient safety efforts, a robust methodology is needed for analyzing human errors that defeat individual controls within RT quality assurance (QA) programs. We herein demonstrate an adapted use of a human error bowtie analysis to evaluate and optimize the controls expected to protect against the potential for patient harm.

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International Journal of Radiation Oncology*Biology*Physics

PURPOSE We conducted a prospective observational cohort study of physician compliance with daily ... more PURPOSE We conducted a prospective observational cohort study of physician compliance with daily early pretreatment planning peer review recommendations and quantified factors associated with compliance. METHODS AND MATERIALS All patient cases in our department are presented at 2 peer review conferences: (1) "early" preplanning, occurring daily for patients who have undergone simulation review, and (2) "late" (chart rounds), occurring weekly for patients who have started treatment. Peer review recommendations were prospectively recorded during early review, and compliance with recommendations was determined at chart rounds. Recommendations were assigned magnitude scores (minor, moderate, or major). We analyzed the association of patient, physician, and recommendation characteristics and compliance (scored as a binary variable) with early peer review recommendations, using logistic regression with a mixed effects model. RESULTS From February 2017 to May 2018, 1271 patient cases underwent early peer review, and 326 (26%) received peer-based recommendations. Of 356 recommendations, 37% were minor, 36% were moderate, and 27% were major. Overall compliance was 59% (95% confidence interval, 54%-64%). On univariate analysis, compliance decreased as the recommendation magnitude increased (minor, 65%; moderate, 60%; major, 47%; P = .019; odds ratio, 0.71 per increase in magnitude). Compliance also differed among different treating physicians (range, 38%-73%, χ2 test, P = .003) but was not associated with other physician characteristics. Disease group and treatment technique were not associated with compliance. On multivariable analysis, increasing recommendation magnitude remained significantly associated with decreased compliance (multivariate P = .042; odds ratio, 0.74). CONCLUSIONS Daily early peer review resulted in a substantial proportion of recommended changes. Compliance with early peer review recommendations was fair but varied among physicians. Compliance declined with increasing recommendation magnitude, suggesting that physicians may be reluctant to adopt major changes. These results highlight the potential importance of peer review timing.

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International Journal of Human–Computer Interaction

ABSTRACT The goal of this study was to assess the relationship of task difficulty and mental effo... more ABSTRACT The goal of this study was to assess the relationship of task difficulty and mental effort with performance during physicians’ interaction with electronic health records (EHRs). A total of 38 physicians were asked to identify abnormal results and take follow-up action to “close the loop” on care delivery. Task difficulty was quantified via task-flow strategies and computer mouse-click patterns. Mental effort was quantified using eye movements based on changes in pupillary dilations (task evoked pupillary response or TEPR) and blink rate. Performance was quantified based on commission errors (error vs. no-error). Results indicated that physicians had different task-flow strategies; however, with improved awareness of the patient status, they exhibited an optimal task-flow strategy. Overall, performance was related to task-flow strategies, computer mouse-click patterns, and blink rate, indicating that physicians had lower task-difficulty and experienced lower mental effort with improved awareness of patient follow-up status. This is an important finding demonstrating that task-flows are a dominant predictor of physician performance when comparing between EHR designs. On the contrary, mouse-click patterns and blink rate are both useful predictors of physician performance when assessment was done within an EHR.

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Practical Radiation Oncology

PURPOSE This study aimed to present an innovative approach to quantify, visualize, and predict ra... more PURPOSE This study aimed to present an innovative approach to quantify, visualize, and predict radiation therapy (RT) process reliability using data captured from a voluntary incident learning system, with an overall aim to improve patient safety outcomes. METHODS AND MATERIALS We analyzed 111 reported deviations that were tripped and caught within 159 mapped RT process steps included within 7 major stages of RT delivery, 94 of which were any type of quality assurance (QA) controls. This allowed for us to compute the trip rate and fail-to-catch-rate (FCR) per each QA control with the available data. Next, we used a logistic regression model to identify significant variables predictive of FCRs, predicted FCRs for each QA control without available data, and thus, attempted to quantify RT process reliability expressed as percentage of patients with uncaught deviations after treatment planning, before their first treatment, and during treatment delivery. RESULTS Using the predicted FCRs, we computed the upper 95% likelihood that a deviation remains uncaught in a patient's course of treatment at the following RT process stages: immediately after treatment planning at 10.26%; before the first treatment at 0.0052%; and throughout treatment delivery at 0.0276%. CONCLUSIONS The results suggest that RT process reliability can be predicted and visualized using data from incident learning systems. If implemented and used as a safety metric, this could help RT clinics to proactively maintain their preoccupation with patient safety. RT process reliability may also help guide future work on standardization and continuous improvement of the design of RT QA programs.

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International Journal of Radiation Oncology*Biology*Physics

Summary This commentary is aimed at reconciling the 'conflict' between increased variabil... more Summary This commentary is aimed at reconciling the 'conflict' between increased variability potentially caused by medical personalization with the need for decreased variability as spearheaded by quality improvement efforts in practice - two concepts that may seem inherently contradictory, but in fact they are mutually depended.

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International Journal of Human–Computer Interaction

ABSTRACT Objective was to assess the relationship between task demand, mental effort, task diffic... more ABSTRACT Objective was to assess the relationship between task demand, mental effort, task difficulty, and performance during physicians’ interaction with electronic health records (EHRs). Seventeen physicians performed three EHR-based scenarios with varying task demands. Mental effort was measured using eye tracking measures via task evoked pupillary responses (TEPR), blink frequency, and gaze speed; task difficulty (or user behavior) was measured using frequent mouse click patterns and task flow; user performance was quantified using two types of omission errors: (i) omission errors with no evidence of trying to complete the task and (ii) omission error with evidence of trying but unable to complete the task. The results indicated that task demand significantly increased mental effort, but not task difficulty. Task demand, mental effort, and task difficulty all predicted performance. Specifically, there was a significant relationship between (i) task demand, TEPR and omission errors with no evidence of trying to complete the task, and (ii) blink frequency, repeated search clicks and omission error with evidence of trying but unable to complete the task. In concert, results suggest that physicians’ performance during EHR interaction was negatively affected by task demands and increase in mental effort. This highlight the need for implementation of appropriate quality assurance (QA) measures, in addition to EHR usability improvement, to minimize omission errors and improve physician’s performance. Additionally, the lack of relationship between task demand and task difficulty highlights a need for further methodological and empirical studies to advance our understanding from theory to application during physician–EHR interaction.

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Journal of oncology practice, Aug 26, 2017

To identify factors associated with a near-miss or safety incident (NMSI) in patients undergoing ... more To identify factors associated with a near-miss or safety incident (NMSI) in patients undergoing radiotherapy and identify common root causes of NMSIs and their relationship with incident severity. We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with an NMSI (n = 200; incident group) and a similar group of control patients (n = 200) matched in time, without an NMSI. A root cause and incident severity were determined for each NMSI. Univariable and multivariable analyses were performed to determine which specific factors were contributing to NMSIs. Multivariable logistic regression was used to determine root causes of NMSIs and their relationship with incident severity. NMSIs were associated with the following factors: head and neck sites (odds ratio [OR], 5.2; P = .01), image-guided intensity-modulated radiotherapy (OR, 3; P = .009), daily imaging (OR, 7; P < .001), and tumors st...

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International journal of radiation oncology, biology, physics, Jun 1, 2017

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Ergonomics, Jan 15, 2017

The methods employed to quantify the baseline pupil size and task-evoked pupillary response (TEPR... more The methods employed to quantify the baseline pupil size and task-evoked pupillary response (TEPR) may affect the overall study results. To test this hypothesis, the objective of this study was to assess variability in baseline pupil size and TEPR during two basic working memory tasks: constant load of 3-letters memorisation-recall (10 trials), and incremental load memorisation-recall (two trials of each load level), using two commonly used methods (1) change from trail/load specific baseline, (2) change from constant baseline. Results indicated that there was a significant shift in baseline between the trails for constant load, and between the load levels for incremental load. The TEPR was independent of shifts in baseline using method 1 only for constant load, and method 2 only for higher levels of incremental load condition. These important findings suggest that the assessment of both the baseline and methods to quantify TEPR are critical in ergonomics application, especially in ...

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HERD, Jan 7, 2016

To explore what, when, and how Lean methods and tools can add value during the programming phase ... more To explore what, when, and how Lean methods and tools can add value during the programming phase of design through providing additional resources and support to project leadership and the architectural design team. This case study-based research took place at one large academic hospital during design efforts of a surgical tower to house 19 operating rooms (ORs) and support spaces including pre- and postop, central processing and distribution, and materials management. Surgical services project leadership asked for support from Lean practitioners during the design process. Lean exploration loops (LELs) were conducted to generate evidence to support stakeholders, as they made important decisions about the new building design. The analyses conducted during LELs were primarily focused on the relative advantages of a large footprint with few floors or a smaller footprint with more floors and support spaces not collocated adjacent to ORs on the same floor. LELs resulted in quantifications...

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Proceedings of the 2016 ACM on Conference on Human Information Interaction and Retrieval - CHIIR '16, 2016

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Advances in Intelligent Systems and Computing, 2016

The objective of this research was to compare classification methods aimed at predicting working ... more The objective of this research was to compare classification methods aimed at predicting working memory (WM) load. Electroencephalogram (EEG) data was collected from physicians while performing basic WM tasks and simulated medical scenarios. Data processing was performed to remove noise from the signal used for analysis (e.g., muscle activity, eye-blinks). The data from basic WM tasks was used to develop and test the four classification models (LASSO regression, support vector machines (SVM), nearest shrunken centroids (NSC), and iterated supervised principal components (ISPC) to predict a WM state indicative of physicians’ optimal performance. The naive misclassification rate was 19.74 %; LASSO and SVM outperformed this threshold: 18.10 and 12.21 % respectively). Both classification models had relatively high-specificity (LASSO: 97.2 %; SVM: 99.8 %); but relatively low-sensitivity LASSO: 20.7 %; SVM: 39.6 %). Results from simulated medical scenarios suggest that physicians were approximately 83 % of the time in the WM state that is likely indicative of optimal performance.

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Advances in Intelligent Systems and Computing, 2016

The objective of this pilot study was to assess the inter-rater reliability of a newly developed ... more The objective of this pilot study was to assess the inter-rater reliability of a newly developed A3 Quality Assessment (QA) rubric to evaluate the quality of completed Plan-Do-Study-Act (PDSA) projects that used an A3 Thinking Tool (A3) for problem solving. One A3 was independently reviewed by 7 PDSA experts using 5 main levels and 22 sublevels. Evaluations were compared and coded for agreement and used for statistical analysis. Fleiss’ kappa statistics was performed to test for inter-rater reliability between experts across 5 main and 22 sublevels. Preliminary results suggest that the A3 QA rubric meets reliability criteria with a moderate level of agreement beyond chance alone (κ = 0.44) and it is applicable to measure progress on problem solving abilities spearheaded via PDSA cycles. Additional verification testing is needed across multiple A3 improvement projects completed in multiple A3 Thinking templates.

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Advances in radiation oncology

There is a need to better prepare radiation therapy (RT) providers to safely operate within the h... more There is a need to better prepare radiation therapy (RT) providers to safely operate within the health information technology (IT) sociotechnical system. Simulation-based training has been preemptively used to yield meaningful improvements during providers' interactions with health IT, including RT settings. Therefore, on the basis of the available literature and our experience, we propose principles for the effective design and use of simulated scenarios and describe a conceptual framework for a debriefing approach to foster successful training that is focused on safety mindfulness during RT professionals' interactions with health IT.

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DESALINATION AND WATER TREATMENT

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Suboptimal usability within electronic health records (EHRs) can pose risks for patient safety. T... more Suboptimal usability within electronic health records (EHRs) can pose risks for patient safety. This study uses data collected in a simulated environment in which providers interacted with ‘current’ and ‘enhanced’ Epic EHR interfaces to manage patients’ test results and missed appointments. Interactions were quantified and categorized by high or low burden in terms of displayed behavioral and physiological data. Using recorded video data, providers’ workflow and performance was analyzed. Suboptimal performance was found to be associated with high burden levels.

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting

Usability and cognitive workload (CWL) are multidimensional constructs that describe user experie... more Usability and cognitive workload (CWL) are multidimensional constructs that describe user experience, predict performance, and inform system design. The relationship between the subjective measures of these constructs has not been adequately explored, especially in healthcare delivery settings where suboptimal usability of electronic health records and CWL of healthcare professionals are among the major contributing factors to medical errors. This study quantifies the perceived usability of a dosimetry quality assurance (QA) checklist and the perceived CWL of dosimetrists in radiation oncology clinical settings of an academic medical center and investigates the association between perceived usability and perceived CWL. Findings suggest that our institutional dosimetry QA checklist has suboptimal usability, but the associated CWL is acceptable. Further, the correlation analysis reveals that perceived usability and perceived CWL are non-overlapping constructs and may be jointly employ...

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Journal of the American College of Surgeons

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Frontiers in Oncology

Purpose/Objectives: Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT... more Purpose/Objectives: Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) may be considered “high risk” due to the high doses per fraction. We analyzed CyberKnife™ (CK) SRS and SBRT-related incidents that were prospectively reported to our in-house incident learning system (ILS) in order to identify severity, contributing factors, and common error pathways. Material and Methods: From 2012 to 2019, 221 reported incidents related to the 4,569 CK fractions delivered (5.8%) were prospectively analyzed by our multi-professional Quality and Safety Committee with regard to severity, contributing factors, as well as the location where the incident occurred (tripped), where it was discovered (caught), and the safety barriers that were traversed (crossed) on the CK process map. Based on the particular step in the process map that incidents tripped, we categorized incidents into general error pathways. Results: There were 205 severity grade 1–2 (did not reach patient or no clinical impact), 11 grade 3 (clinical impact unlikely), 5 grade 4 (altered the intended treatment), and 0 grade 5–6 (life-threatening or death) incidents, with human performance being the most common contributing factor (79% of incidents). Incidents most commonly tripped near the time when the practitioner requested CK simulation (e.g., pre-CK simulation fiducial marker placement) and most commonly caught during the physics pre-treatment checklist. The four general error pathways included pre-authorization, billing, and scheduling issues (n= 119); plan quality (n= 30); administration of IV contrast during simulation or pre-medications during treatment (n= 22); and image guidance (n= 12). Conclusion: Most CK incidents led to little or no patient harm and most were related to billing and scheduling issues. Suboptimal human performance appeared to be the most common contributing factor to CK incidents. Additional study is warranted to develop and share best practices to reduce incidents to further improve patient safety.

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Engineering Management Journal

Abstract Despite positive reports about lean approaches to spearhead quality and patient safety i... more Abstract Despite positive reports about lean approaches to spearhead quality and patient safety improvement efforts, it is still difficult to determine if healthcare employees have transformed into effective lean thinkers. Lean thinking refers to individuals who operate with thoughtful reflection on organizational issues, are committed to continuous improvement efforts, and demonstrate the willingness to lead change. The objective of this theory building research is to contribute a survey instrument and conceptual model to measure individual transformation to lean thinking. Our learnings from the case study suggest that healthcare a professional’s transition to lean thinking via a complex combination of awareness issues at both the unit and individual levels, and both levels should be considered when moving individuals toward readiness and through a personal transformation to lean thinking.

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Practical Radiation Oncology

While the vast majority of radiation treatments (RT) are effective and carried out without result... more While the vast majority of radiation treatments (RT) are effective and carried out without resulting in patient harm, quality and safety events of varying clinical significance do occur. Ensuring safety within RT is of paramount importance. To further support and augment patient safety efforts, a robust methodology is needed for analyzing human errors that defeat individual controls within RT quality assurance (QA) programs. We herein demonstrate an adapted use of a human error bowtie analysis to evaluate and optimize the controls expected to protect against the potential for patient harm.

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International Journal of Radiation Oncology*Biology*Physics

PURPOSE We conducted a prospective observational cohort study of physician compliance with daily ... more PURPOSE We conducted a prospective observational cohort study of physician compliance with daily early pretreatment planning peer review recommendations and quantified factors associated with compliance. METHODS AND MATERIALS All patient cases in our department are presented at 2 peer review conferences: (1) "early" preplanning, occurring daily for patients who have undergone simulation review, and (2) "late" (chart rounds), occurring weekly for patients who have started treatment. Peer review recommendations were prospectively recorded during early review, and compliance with recommendations was determined at chart rounds. Recommendations were assigned magnitude scores (minor, moderate, or major). We analyzed the association of patient, physician, and recommendation characteristics and compliance (scored as a binary variable) with early peer review recommendations, using logistic regression with a mixed effects model. RESULTS From February 2017 to May 2018, 1271 patient cases underwent early peer review, and 326 (26%) received peer-based recommendations. Of 356 recommendations, 37% were minor, 36% were moderate, and 27% were major. Overall compliance was 59% (95% confidence interval, 54%-64%). On univariate analysis, compliance decreased as the recommendation magnitude increased (minor, 65%; moderate, 60%; major, 47%; P = .019; odds ratio, 0.71 per increase in magnitude). Compliance also differed among different treating physicians (range, 38%-73%, χ2 test, P = .003) but was not associated with other physician characteristics. Disease group and treatment technique were not associated with compliance. On multivariable analysis, increasing recommendation magnitude remained significantly associated with decreased compliance (multivariate P = .042; odds ratio, 0.74). CONCLUSIONS Daily early peer review resulted in a substantial proportion of recommended changes. Compliance with early peer review recommendations was fair but varied among physicians. Compliance declined with increasing recommendation magnitude, suggesting that physicians may be reluctant to adopt major changes. These results highlight the potential importance of peer review timing.

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International Journal of Human–Computer Interaction

ABSTRACT The goal of this study was to assess the relationship of task difficulty and mental effo... more ABSTRACT The goal of this study was to assess the relationship of task difficulty and mental effort with performance during physicians’ interaction with electronic health records (EHRs). A total of 38 physicians were asked to identify abnormal results and take follow-up action to “close the loop” on care delivery. Task difficulty was quantified via task-flow strategies and computer mouse-click patterns. Mental effort was quantified using eye movements based on changes in pupillary dilations (task evoked pupillary response or TEPR) and blink rate. Performance was quantified based on commission errors (error vs. no-error). Results indicated that physicians had different task-flow strategies; however, with improved awareness of the patient status, they exhibited an optimal task-flow strategy. Overall, performance was related to task-flow strategies, computer mouse-click patterns, and blink rate, indicating that physicians had lower task-difficulty and experienced lower mental effort with improved awareness of patient follow-up status. This is an important finding demonstrating that task-flows are a dominant predictor of physician performance when comparing between EHR designs. On the contrary, mouse-click patterns and blink rate are both useful predictors of physician performance when assessment was done within an EHR.

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Practical Radiation Oncology

PURPOSE This study aimed to present an innovative approach to quantify, visualize, and predict ra... more PURPOSE This study aimed to present an innovative approach to quantify, visualize, and predict radiation therapy (RT) process reliability using data captured from a voluntary incident learning system, with an overall aim to improve patient safety outcomes. METHODS AND MATERIALS We analyzed 111 reported deviations that were tripped and caught within 159 mapped RT process steps included within 7 major stages of RT delivery, 94 of which were any type of quality assurance (QA) controls. This allowed for us to compute the trip rate and fail-to-catch-rate (FCR) per each QA control with the available data. Next, we used a logistic regression model to identify significant variables predictive of FCRs, predicted FCRs for each QA control without available data, and thus, attempted to quantify RT process reliability expressed as percentage of patients with uncaught deviations after treatment planning, before their first treatment, and during treatment delivery. RESULTS Using the predicted FCRs, we computed the upper 95% likelihood that a deviation remains uncaught in a patient's course of treatment at the following RT process stages: immediately after treatment planning at 10.26%; before the first treatment at 0.0052%; and throughout treatment delivery at 0.0276%. CONCLUSIONS The results suggest that RT process reliability can be predicted and visualized using data from incident learning systems. If implemented and used as a safety metric, this could help RT clinics to proactively maintain their preoccupation with patient safety. RT process reliability may also help guide future work on standardization and continuous improvement of the design of RT QA programs.

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International Journal of Radiation Oncology*Biology*Physics

Summary This commentary is aimed at reconciling the 'conflict' between increased variabil... more Summary This commentary is aimed at reconciling the 'conflict' between increased variability potentially caused by medical personalization with the need for decreased variability as spearheaded by quality improvement efforts in practice - two concepts that may seem inherently contradictory, but in fact they are mutually depended.

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International Journal of Human–Computer Interaction

ABSTRACT Objective was to assess the relationship between task demand, mental effort, task diffic... more ABSTRACT Objective was to assess the relationship between task demand, mental effort, task difficulty, and performance during physicians’ interaction with electronic health records (EHRs). Seventeen physicians performed three EHR-based scenarios with varying task demands. Mental effort was measured using eye tracking measures via task evoked pupillary responses (TEPR), blink frequency, and gaze speed; task difficulty (or user behavior) was measured using frequent mouse click patterns and task flow; user performance was quantified using two types of omission errors: (i) omission errors with no evidence of trying to complete the task and (ii) omission error with evidence of trying but unable to complete the task. The results indicated that task demand significantly increased mental effort, but not task difficulty. Task demand, mental effort, and task difficulty all predicted performance. Specifically, there was a significant relationship between (i) task demand, TEPR and omission errors with no evidence of trying to complete the task, and (ii) blink frequency, repeated search clicks and omission error with evidence of trying but unable to complete the task. In concert, results suggest that physicians’ performance during EHR interaction was negatively affected by task demands and increase in mental effort. This highlight the need for implementation of appropriate quality assurance (QA) measures, in addition to EHR usability improvement, to minimize omission errors and improve physician’s performance. Additionally, the lack of relationship between task demand and task difficulty highlights a need for further methodological and empirical studies to advance our understanding from theory to application during physician–EHR interaction.

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Journal of oncology practice, Aug 26, 2017

To identify factors associated with a near-miss or safety incident (NMSI) in patients undergoing ... more To identify factors associated with a near-miss or safety incident (NMSI) in patients undergoing radiotherapy and identify common root causes of NMSIs and their relationship with incident severity. We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with an NMSI (n = 200; incident group) and a similar group of control patients (n = 200) matched in time, without an NMSI. A root cause and incident severity were determined for each NMSI. Univariable and multivariable analyses were performed to determine which specific factors were contributing to NMSIs. Multivariable logistic regression was used to determine root causes of NMSIs and their relationship with incident severity. NMSIs were associated with the following factors: head and neck sites (odds ratio [OR], 5.2; P = .01), image-guided intensity-modulated radiotherapy (OR, 3; P = .009), daily imaging (OR, 7; P < .001), and tumors st...

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International journal of radiation oncology, biology, physics, Jun 1, 2017

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Ergonomics, Jan 15, 2017

The methods employed to quantify the baseline pupil size and task-evoked pupillary response (TEPR... more The methods employed to quantify the baseline pupil size and task-evoked pupillary response (TEPR) may affect the overall study results. To test this hypothesis, the objective of this study was to assess variability in baseline pupil size and TEPR during two basic working memory tasks: constant load of 3-letters memorisation-recall (10 trials), and incremental load memorisation-recall (two trials of each load level), using two commonly used methods (1) change from trail/load specific baseline, (2) change from constant baseline. Results indicated that there was a significant shift in baseline between the trails for constant load, and between the load levels for incremental load. The TEPR was independent of shifts in baseline using method 1 only for constant load, and method 2 only for higher levels of incremental load condition. These important findings suggest that the assessment of both the baseline and methods to quantify TEPR are critical in ergonomics application, especially in ...

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HERD, Jan 7, 2016

To explore what, when, and how Lean methods and tools can add value during the programming phase ... more To explore what, when, and how Lean methods and tools can add value during the programming phase of design through providing additional resources and support to project leadership and the architectural design team. This case study-based research took place at one large academic hospital during design efforts of a surgical tower to house 19 operating rooms (ORs) and support spaces including pre- and postop, central processing and distribution, and materials management. Surgical services project leadership asked for support from Lean practitioners during the design process. Lean exploration loops (LELs) were conducted to generate evidence to support stakeholders, as they made important decisions about the new building design. The analyses conducted during LELs were primarily focused on the relative advantages of a large footprint with few floors or a smaller footprint with more floors and support spaces not collocated adjacent to ORs on the same floor. LELs resulted in quantifications...

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Proceedings of the 2016 ACM on Conference on Human Information Interaction and Retrieval - CHIIR '16, 2016

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Advances in Intelligent Systems and Computing, 2016

The objective of this research was to compare classification methods aimed at predicting working ... more The objective of this research was to compare classification methods aimed at predicting working memory (WM) load. Electroencephalogram (EEG) data was collected from physicians while performing basic WM tasks and simulated medical scenarios. Data processing was performed to remove noise from the signal used for analysis (e.g., muscle activity, eye-blinks). The data from basic WM tasks was used to develop and test the four classification models (LASSO regression, support vector machines (SVM), nearest shrunken centroids (NSC), and iterated supervised principal components (ISPC) to predict a WM state indicative of physicians’ optimal performance. The naive misclassification rate was 19.74 %; LASSO and SVM outperformed this threshold: 18.10 and 12.21 % respectively). Both classification models had relatively high-specificity (LASSO: 97.2 %; SVM: 99.8 %); but relatively low-sensitivity LASSO: 20.7 %; SVM: 39.6 %). Results from simulated medical scenarios suggest that physicians were approximately 83 % of the time in the WM state that is likely indicative of optimal performance.

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Advances in Intelligent Systems and Computing, 2016

The objective of this pilot study was to assess the inter-rater reliability of a newly developed ... more The objective of this pilot study was to assess the inter-rater reliability of a newly developed A3 Quality Assessment (QA) rubric to evaluate the quality of completed Plan-Do-Study-Act (PDSA) projects that used an A3 Thinking Tool (A3) for problem solving. One A3 was independently reviewed by 7 PDSA experts using 5 main levels and 22 sublevels. Evaluations were compared and coded for agreement and used for statistical analysis. Fleiss’ kappa statistics was performed to test for inter-rater reliability between experts across 5 main and 22 sublevels. Preliminary results suggest that the A3 QA rubric meets reliability criteria with a moderate level of agreement beyond chance alone (κ = 0.44) and it is applicable to measure progress on problem solving abilities spearheaded via PDSA cycles. Additional verification testing is needed across multiple A3 improvement projects completed in multiple A3 Thinking templates.

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