Duke University Human Factors Analysis

Performance Assessment Technology that improved organizational performance by optimizing individual and team performance

The Challenge

The leading edge of practice is a risky place. The unit has experienced several sentinel adverse-patient events, the turnover of nursing staff has grown, and there is debate that some practices may conflict with prescribed procedures. In the face of these and other challenges, Duke Health retained Aptima and Jbara to conduct a human factors analysis of the Pediatric Bone Marrow Unit’s operations.

The Solution

Aptima and Jbara’s human factors analysis addresses an organization as a complex socio-technical system; it identifies the stress points system and redesigns it to prevent errors from occurring, trap them while they are inconsequential, or mitigate their effects. More positively, redesign of systems helps people and machines do the right thing with less effort.

We engaged a multi-disciplinary team of staff and consultants in this work: specialists in clinical safety, decision making, teamwork, engineering, computational modeling, psycho-social services, long-term critical care. Members of this team collected data through document reviews and more than 50 individual interviews, focused group interviews, and direct observations of procedures. The participants were mainly stakeholders in the PBMTU – including nurses, physicians, psycho-social specialists, administrators, and parents – and, to a lesser extent, members of the larger Duke University Hospital of which it is a part.

All members of the team participated in data analysis and contributed to this report of findings, recommendations for action, potential risks, and measures of process and effects. In addition, we developed a computational model of work during the line change period in order to safely, rapidly test the effects on workload of changes to staffing and procedures.

Medical information systems and clinical procedures must be designed to fit one another. An example: The OR Wall of Knowledge is designed to maintain the shared situational awareness of the OR team during surgery.


The recommendations from this research fall into several categories that constitute the clinical microsystem framework (Mohr, Batalden, and Barach, 2004; Barach & Mohr, 2006). We urge PBMTU and the hospital to debate and take decisive action on several recommendations, in particular: to increase the number of nurses during peak work periods (see 1.1 Organizational structure, below), increase and clarify the role of psycho-social services (see 2.1 Interdependence), and develop PBMTU-specific training in specific knowledge and skills (see 2.3 Education and training).

These changes should:

  • Improve the quality of care to patients
  • Decrease the likelihood of lawsuits over sentinel events
  • Increase staff retention, thus lowering recruitment and training costs
  • Enable the PBMTU to safely grow its practice, thus increasing revenue

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