Fellow’s Corner: Studying Human Factors in the Delivery Room

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Children's Doctor

All pediatricians spent significant time in the delivery room during their training, and many continue to visit the delivery room as part of their careers. While the majority of infants perform the transition from in utero to ex utero without assistance, the American Academy of Pediatrics Neonatal Resuscitation Program (NRP) is essential for approximately 10% of newborns who require resuscitation at birth.

NRP is an effective and specific algorithm of the medical steps for neonatal resuscitation, but performing effective resuscitation goes beyond just the medical steps. The delivery room is a complex system that requires the interplay and coordination of a multitude of factors, including provider training, teamwork, communication, proper equipment, and an appropriate space. Given the complex interaction of patient, provider, and environmental factors, there is a critical knowledge gap about how to optimize this setting to maximize our ability to perform effective NRP.

Human factors (HF), defined as the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, offers a unique perspective for evaluating the delivery room. HF has been applied to complex systems across almost all industries, most notably aviation, helping to improve safety and efficiency. The study of HF in aviation has yielded many valuable lessons about humans within complex systems:

  1. Humans are a fundamental component of any system: They are uniquely able to function in uncertainty and make trade-offs, and they can create safety in complex systems.
  2. Complex systems are inherently unsafe: They always function at the limits of capacity, and they require safety to be traded for other aspects of system performance.

Susan Dekker summarized this well: “Human error is the inevitable byproduct of the pursuit of success in an imperfect, unstable, resource-constrained world.”

These concepts are readily transferable to the healthcare setting, with particular application to improving the safety and quality of care provided. Healthcare, like any other industry, is filled with complex systems, which human factors can help streamline and improve. The delivery room is one of these complex systems. Most studies beginning to examine human factors in Neonatology have focused on deviations from NRP or the standardization of communication within the delivery room. While identifying errors during delivery room resuscitation is important, the critical gap is identifying the systematic conditions that predispose to these errors.

Flow disruption, defined as “deviations from the progression of care that compromise safety and efficiency of a specific process” derived from direct observations of clinical work, is a tool developed specifically to quantify the impact of human factors in high-acuity medical settings. I am currently receiving funding through the NRP Young Investigators Award to study flow disruption in the delivery room. Through this work I hope to identify ways to apply human factors to the delivery room setting, reducing preventable errors that result from flow disruptions.

References and suggested readings

Dekker S. The Field Guide to Understanding ‘Human Error.’ Farnham, Surrey, England: Ashgate; 2014.

Wiegmann D, et al. Disruptions in surgical flow and their relationship to surgical errors: An exploratory investigation. Surgery. 2007;142(5):658-665.

Catchpole K, et al. A Human Factors Subsystem Approach to Trauma Care. JAMA Surg. 2014;149(9):962-968.

ElBardissi A, et al. Application of the Human Factors Analysis and Classification System Methodology to the Cardiovascular Surgery Operating Room. Ann Thorac Surg, 2007;83:1412-1419.