Human Factors Engineering and Patient Safety. Michigan Health & Safety Coalition – Annual Conference John Gosbee, MD, MS VA National Center for Patient Safety www.patientsafety.gov. Introductions. Mine Human factors engineering and healthcare specialist Adverse events and patient safety
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Michigan Health & Safety Coalition – Annual Conference
John Gosbee, MD, MS
VA National Center for Patient Safety
a.A few people would notice, but it would not increase accidents
b.It would have no effect
c.It would have a measurable effect with an increased accident rate
d.A few people who are day-dreaming would miss the signs, but not those that cared and were paying attention
e.Radio warnings and cautions to pay more attention would not help
- Vision - Hearing
- Color display - Sound
HONOLULU - A medical mistake at Tripler Army Medical Center has left a newborn baby in a coma with severe brain damage. Sources familiar with this case tell KITV 4 News that Tripler officials apologized to the family of a baby boy born there in January after he was mistakenly given carbon dioxide right after birth, instead of oxygen.
The baby boy was born Jan. 14 at Tripler Army Medical Center during a scheduled cesarean section delivery, sources told KITV 4 News.
They said medical personnel mistakenly gave him carbon dioxide immediately after birth instead of oxygen. Sources said the operating room may have been set up incorrectly.
Note the multiple orientations
Note the lack of labels for each spot
1. Simple and Natural Dialogue
2. Speak the Users’ Language
3. Minimizing User Memory Load
4 . Consistency
6. Clearly Marked “Exits”
7. Prevent Errors
This piece of tape says “On/Off”