{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,2]],"date-time":"2025-11-02T22:19:41Z","timestamp":1762121981032,"version":"build-2065373602"},"reference-count":29,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2025,8,26]],"date-time":"2025-08-26T00:00:00Z","timestamp":1756166400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,10,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Chest tubes are a standard procedure. Despite it being a regular intervention, complication rates can be up to 30%, impacting patient\u2019s health, morbidity, and mortality. Checklists have been shown to reduce complications for other medical procedures. Data on implementing a checklist are increasing, while data on the development are still low. A guide on analysing and designing a chest tube accordingly has not yet been published. Therefore, the aim of the study is to introduce a structured design of a chest tube checklist based on analyses using human factor analysis tools.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A multifactor analysis was performed focusing on chest tube insertion and possible complications using hierarchical task analysis, a failure mode and effective analysis (FMEA), and a bow-tie analysis. The data were collected through a workshop in addition to published literature on chest tube complications.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The FMEA revealed events with a high level of risk priority numbers (RPNs). In total, 247 RPNs were calculated. Failure modes adding up to 147 RPNs were summarized as \u2018malposition of chest tube\u2019. \u2018Lack of sterility\u2019 accounted for 100 RPNs. The FMEA revealed the importance of indication, preparation, and equipment in assessing risk and ultimate failure. \u2018Malpositioning of chest tube\u2019 was used for the bow-tie analysis. Contributing factors were extracted from the FMEA, preventative controls, recovery barriers and consequences analysed the lack of sterility was addressed by \u2018preventative controls\u2019, recovery barriers and consequences in preparation, equipment, and chest tube insertion. Based on these findings, a checklist was designed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Human factor analysis tools can be used to analyse procedure\u2019s complications and its causes. Future data will need to show the effectiveness of the checklist.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/intqhc\/mzaf083","type":"journal-article","created":{"date-parts":[[2025,8,24]],"date-time":"2025-08-24T11:32:32Z","timestamp":1756035152000},"source":"Crossref","is-referenced-by-count":0,"title":["Designing a chest tube checklist using a multidimensional human factor approach: a hierarchical task analysis, a failure mode and effect analysis, and a bow-tie analysis"],"prefix":"10.1093","volume":"37","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3895-5318","authenticated-orcid":false,"given":"Johanna","family":"Ludwig","sequence":"first","affiliation":[{"name":"Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin , Warener Stra\u00dfe 7 , 12683 Berlin,","place":["Germany"]},{"name":"Kellogg College, University of Oxford , 60-62 Banbury Rd, Park Town , Oxford OX2 6PN,","place":["United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephanie","family":"Schneider","sequence":"additional","affiliation":[{"name":"Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin , Warener Stra\u00dfe 7 , 12683 Berlin,","place":["Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Axel","family":"Ekkernkamp","sequence":"additional","affiliation":[{"name":"Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin , Warener Stra\u00dfe 7 , 12683 Berlin,","place":["Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas","family":"Auhuber","sequence":"additional","affiliation":[{"name":"BG prevent GmbH , Herbert-Rabius-Street 1, 53225 Bonn,","place":["Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lauren","family":"Morgan","sequence":"additional","affiliation":[{"name":"Morgan Human Systems Ltd , 1 Brassey Road, Old Potts Way, Shrewsbury, Shropshire, England, SY3 7FA ,","place":["United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2025,8,26]]},"reference":[{"key":"2025110217155152100_mzaf083-B1","doi-asserted-by":"crossref","first-page":"1158","DOI":"10.1016\/j.ssci.2011.11.009","article-title":"Systems-based accident analysis methods: a comparison of Accimap, HFACS, and STAMP","volume":"50","author":"Salmon","year":"2012","journal-title":"Saf Sci"},{"key":"2025110217155152100_mzaf083-B2","first-page":"89","article-title":"Proactive safety management in trauma care: applying the human factors analysis and classification system","volume":"40","author":"Cohen","year":"2018","journal-title":"J Healthc Qual Off Publ Natl Assoc Healthc Qual"},{"key":"2025110217155152100_mzaf083-B3","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1016\/S0735-6757(97)90127-3","article-title":"Complication rates of tube thoracostomy","volume":"15","author":"Chan","year":"1997","journal-title":"Am J Emerg Med"},{"key":"2025110217155152100_mzaf083-B4","first-page":"450","article-title":"Chest tube complications: how well are we training our residents?","volume":"50","author":"Ball","year":"2007","journal-title":"Can J Surg"},{"key":"2025110217155152100_mzaf083-B5","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1001\/archsurg.1995.01430050071012","article-title":"Tube thoracostomy. 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