User Interface Techniques to Reduce Wrong Patient Errors

1. Awalin Sopan, Catherine Plaisant, Seth Powsner, Ben Shneiderman User Interface Techniques to Reduce Wrong Patient Errors Human-Computer Interaction Lab & Department of Computer Science, University of Maryland

2. A Tale of Two Patients http://www.nytimes.com/2002/06/18/health/oops-wrong-patient-journal-takes-on-medical-mistakes.html

3. A Tale of Two Patients Mrs. Morrison, 77 Mrs. Morris, 67 • They were in same hospital floor. • Mrs. Morris was taken to the operation room for the heartsurgery

4. Problems • A drug administered to wrong patient • Reading of wrong patients’ test results • Patients miss needed treatment • etc.

5. Is Computerized Patient Order System a Panacea for These Problems?

7. interruption multitasking fatigue urgency long work-hours

8. Our Approach • Error Classification • what are the error-scenarios clinicians face • Task Analysis • which stage is more susceptible to a particular type of error • 27 Specific Techniques • what to do, and then how to do it

9. Error Classification Mistake Slips Failure to recognize

10. Error Classification Recalling the wrong patient due to short term memory failure, name similarity, unfamiliarity with the patient, fatigue. Mistake Slips Failure to recognize

11. Error Classification Mistake Mechanical errors such as wrong key press, mouse slip, or errors due to unreadable fonts and too small button size. Slips Failure to recognize

12. Error Classification Mistake Slips Failures to detect errors due to interruptions, multitasking, absence of relevant information. Failure to recognize

13. Task Analysis

14. Task Analysis

15. Task Analysis

16. Task Analysis

17. Task Analysis

18. UI Techniques:Reduce Mistakes • Facilitate recall: • Provide more context: room number, photo,… • Avoid confusion: • Emphasize the salient features: age, chief complaint,… • Use at least two sources of identification: name, medical record number,…

19. Facilitate Recall Poor recall strategy, more mistakes

21. Other Techniques • Allow sorting • Always show patient’s full name • Scan RFID to retrieve the patient • Use indoor location to retrieve the patients

22. UI Techniques:Reduce Slips • Improve target-selection • Improve text-readability • Highlight target under cursor

23. Facilitate Selection Poor selection mechanism, more slips

25. Other Techniques • Highlight row under cursor • Use an icon-based 2D grid instead of list

26. UI Techniques:Increase Recognition • Draw attention to patient information • Taieb-Maimon et al. : recognition increased from 7% to 43% with photo • Use decision support system

27. Increase Recognition Poor verification, less error recognition

28. During Verification

30. Other Techniques • Use visual summary of patient history • Avoid visual distraction • Re-enter ID

31. During Confirmation

33. What Guided Us • Human Error Classification • Attention Theory • Context Recovery Process • Cognitive Task Analysis • User Interface Design Principles • Expert Feedback • Medical Literature

34. Contributions • Categorization of the error-types, and sources • Suggestions of User Interface remedies • Prototype demonstrating the techniques

35. Take-away Messages • Small changes in the UI can make big difference in patient safety • Include Clinicians and HCI researchers in the design process • To err is human, the systems should make up for it

36. www.cs.umd.edu/hcil/WPE www.youtube.com/watch?v=CrwOJIrnsg8 Awalin Sopan, Catherine Plaisant, Seth Powsner, Ben Shneiderman @awalinsopan awalin@cs.umd.edu We thank the Patient-Centered Cognitive Support under the Strategic Health IT Advanced Research Projects Program (SHARP) from the Office of the National Coordinator for Health Information Technology (Grant No. 10510592).