human factors engineering and patient safety l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Human Factors Engineering and Patient Safety PowerPoint Presentation
Download Presentation
Human Factors Engineering and Patient Safety

Loading in 2 Seconds...

play fullscreen
1 / 60

Human Factors Engineering and Patient Safety - PowerPoint PPT Presentation


  • 291 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Human Factors Engineering and Patient Safety' - paul


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
human factors engineering and patient safety

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
Introductions
  • Mine
    • Human factors engineering and healthcare specialist
      • Adverse events and patient safety
      • Curriculum for residents and students
      • Invention and innovation
  • Yours
    • 2 minutes to meet your neighbor
    • Your role and why you chose this break-out session
objectives
Objectives
  • Learn about human factors engineering to help improve
    • Root Cause/Contributing Factors for RCAs
    • Failure Modes/Causes for FMEAs
  • Begin to understand the scope of HFE is beyond devices
    • Work areas and entire buildings
human factors engineering
Human Factors Engineering
  • Interaction between human and system
  • Dialogue between end-user and their tools
  • Tools and concepts to help us with patient safety
  • A short quiz to get us started
if someone painted all the stop signs in your town green which statement is true
If someone painted all the stop signs in your town green, which statement is true?

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

hfe quiz cont
HFE Quiz (cont.)
  • Which blue knob controls the dial on the right? Why?

Control Panel

human factors model
Human Factors Model
  • Psychomotor
  • Hand
  • - Feet
  • Input Devices
  • Buttons
  • - Foot pedal

INTERFACE

Senses

- Vision - Hearing

Output

- Color display - Sound

performance graph curve
Performance Graph (curve)

100%

90%

80%

70%

Performance

1

2

3

4

Time (hours)

slide11

Performance Graph (curve)

100%

90%

80%

70%

Performance

1

2

3

4

Time (hours)

how can we move the curve upwards
How can we move the curve upwards?

100%

90%

80%

70%

Performance

1

2

3

4

Time (hours)

another demonstration with a patient safety twist
Another Demonstration with a Patient Safety Twist
  • Look at the next slide
  • Count the number of words in the paragraph that are repeated
medical device correlation
Medical Device Correlation
  • What does this phrase mean  “Telemetry Off”
  • To a novice? To an expert?
what is this regulator used for
What is this regulator used for?
  • Write your answer down on paper
slide17

Sources: Medical Mistake Left Newborn In Coma

KITV-TV

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.

volunteer to write instructions
Volunteer to Write Instructions
  • Starting from Peanut Butter Jar and Bag of Bread
  • Ending with - peanut butter sandwich (two slices of bread) on the plate
the normalization of complexity
The Normalization of Complexity
  • Healthcare workers compensate for complex, unclear workplaces and devices
    • IV Pumps, for example
    • Unclear or absent information or cues to understand how to accomplish desired goal
    • Mastery of the complex becomes a normal strategy, without regard to reasonableness or necessity of complexity
broad impact of human factors engineering
Broad Impact of Human Factors Engineering
  • Aviation (since 1940’s)
  • Nuclear Power
  • Space flight
  • Computer software and hardware (Xerox PARC 1970s)
  • Consumer products (Palm Pilot, Snakelight)
  • Railroad, motor vehicle, farm machinery, etc.
human factors engineering and your world
Human Factors Engineering and Your World
  • Anesthesiology
    • Design of alarms, monitors, and safety systems
  • Emergency Medicine
    • Design of decision-making tools and monitoring
  • Surgery
    • Design of hand tools and visualization devices (laparoscopy)
healthcare systems range from the simple to complex
Healthcare “Systems”Range from the Simple to Complex
  • Syringe, catheter bag and its tubing
  • O2 cylinder, ECG machine, IV pump
  • Code cart, anesthesia work station
  • Hospital computer system
  • MRI control room and suite
  • ICU, ED, OR
human factors engineering is about the whole system
Human Factors Engineering is about the whole system
  • What’s the design of the training and education
  • Labeling and instructions attached to device
  • Policy and procedures?
  • Information displays
    • Pieces of paper
  • Layout and structure of the room, layout of the floor, layout of the facility, overall environment
design and test of written documents
Design and Test of Written Documents
  • Policies and procedures
    • Steps to use a device
    • Instructions or help screen for software
  • It seems easy, but…
  • Peanut butter sandwich making demo as an example
hfe and patient safety lesson
HFE and Patient Safety Lesson
  • Simple steps never are
  • Learned intuition and assumptions
    • Stereotypes
    • Metaphors
  • Iterative testing of instructions to work the bugs out
learned intuition examples
Learned intuition examples
  • Secretaries using computers
  • Other examples?
baseline drawer laundry hamper range 2 43 3 58 min avg 3 07 min
Baseline Drawer (“Laundry hamper”)Range = 2:43-3:58 min, Avg=3:07 min

Note the multiple orientations

code cart drawer fifth version range 55 1 25 min avg 1 08
Code Cart Drawer Fifth VersionRange = :55-1:25 min, Avg=1:08

Note the lack of labels for each spot

pca programming sequence redesign

Legend

Decision

Message-guided Action

Action

PCA: Programming Sequence Redesign

Existing Design

New Design

usability evaluation of a pca pump measurements
Usability Evaluation of a PCA Pump: Measurements
  • Programming Errors Measured
    • Quantity
    • Severity
  • Performance Measured
    • Programming Time
    • Task completion time
  • Mental Workload Ratings  NASA-TLX
pca pump errors results
PCA Pump Errors - Results
  • New Interface
    • 55% reduction in number of errors
    • Zero errors in entering drug concentration
  • Old interface
    • 8 drug concentration errors were made
    • 3 of these were not detected and were left uncorrected
  • Mode Errors
    • Old interface errors involved selecting the wrong mode (11 errors, 9 of which were eventually corrected
    • With the new interface, only 3 such mode selection errors occurred, all of which were eventually corrected
other results
Other Results
  • Task Completion Time
    • 11/12 end-users faster with new interface
    • Average 18% faster
  • No difference in Subjective Workload
  • Over 90% preference for new interface
how can we apply all of this theory
How can we APPLY all of this theory?
  • Set of principles
    • If they are not followed, adverse events always will
  • Set of guidelines
    • If they are ignored, again, adverse events will occur
  • We will present a short list of guidelines now
human factors engineering guidelines adapted from nielsen 1992
Human Factors Engineering Guidelines (Adapted from Nielsen, 1992)

1. Simple and Natural Dialogue

2. Speak the Users’ Language

3. Minimizing User Memory Load

4 . Consistency

5. Feedback

6. Clearly Marked “Exits”

7. Prevent Errors

  • Good Error Messages
  • Help and Documentation
  • Readable and understandable labels and warnings
simple and natural dialogue
Simple and Natural Dialogue
  • Dialogue is between the user of a device and the device
  • The device communicates to the person with:
    • Physical shape, feel
    • Labeling including symbols and words
    • Characteristics of parts that connect to other devices or a person
    • Environment can affect this dialog in the way that background noise makes hearing difficult
prerequisites for simple natural dialogue
Prerequisites for simple natural dialogue
  • How a device/process/workplace is designed needs to fit with the work done (fit glove to the hand) and the person doing it
  • Because how specific users do their specific jobs gives you
    • Insight into their “mental model”
    • Understanding mismatch between the person and the system design
clinical example radioactivity calculator software
Clinical Example – Radioactivity Calculator Software
  • Used to determine radioactivity of the “pellet” to be placed near the patient’s tumor
  • This determines how long to leave it there during surgery
  • Key data is the date field XX/XX/XX
  • What date is 01/12/99?
consistency
Consistency
  • Controls that look the same act the same
  • Displays or terms that look the same act the same
  • Overall
    • Refer to one item with the same name all the time
    • Conversely, refer to different items with distinct names
consistency42
Consistency
  • Location of controls
    • Typewriter
    • Brake pedal in car
    • Defibrillator
consistency clinical example
Consistency: Clinical Example
  • Your Examples? – testimonials
feedback
Feedback
  • Users want to know what is happening in terms they understand
  • Device or system should indicate current status of the system
  • Examples of feedback from your computer
    • “Beep” when you do certain “bad” things
    • “Thermometer” or “hourglass” display to indicate progress in task
readable and understandable labels and warnings
Readable and understandable labels and warnings
  • Seemingly easy to do…it’s not
  • Thousands of examples, including our own earlier
  • Caused by
    • Jargon
    • Complexity of most design processes
    • Unneeded creativity
clinical example 1 cardiac monitor
Clinical Example #1 – Cardiac Monitor

This piece of tape says “On/Off”

clinical example syringe
Clinical Example – Syringe
  • Syringe labeling on plunger, not syringe itself
  • Harder to read with liquid in the syringe
  • Not usual “measuring cup” model of figuring out volume in syringe
conclusions and next steps
Conclusions and Next Steps
  • HFE contains concepts that underlie patient safety
  • Small group exercises
    • Principles applied to many systems
    • Usability testing method revealed!
  • More resources follow this slide
advamed infusion pump working group
AdvaMed Infusion Pump Working Group
  • Usability Objectives for all future IV pumps
  • Feeding off FDA and ANSO/AAMI 74 guidance
  • Examples
    • 90% min-trained users can turn on pump in 20 sec
    • 85% min-trained can program basics in 5 min
hfe web resources
HFE Web Resources
  • Wiklund M. Eleven Keys to Designing Error-Resistant Medical Devices. MD&DI. May 2002 pp. 86-90. http://www.devicelink.com/mddi/archive/02/05/004.html
  • VA Web Site http://www.patientsafety.gov/hf.html
  • FDA Web Site and Publications (free and good!)
    • http://www.fda.gov/cdrh/humanfactors/
    • Human Factors Engineering and Medical Devices (“Do It By Design” & “Device Use Safety”)
web sites more
Web Sites (more)
  • Human Factors Society (HFES)
    • Website: http://www.hfes.org/
    • Graduate programs in Human Factors
    • Local Chapters of the Human Factors Society
  • The Usability Professionals Association (UPA)
    • Website: http://www.upassoc.org/index.html
    • Local Chapters of the Usability Prof Association
  • ACM-Special Interest Group on Computer-Human Interaction (SIGCHI)
    • Website: http://sigchi.org/
    • Local Chapters of SIGCHI
academia
Academia
  • University of Wisconsin
    • Series of courses for masters in HFE and patient safety
    • Students from nursing, medicine, engineering
    • HFE and BME key to research agenda
    • http://www.engr.wisc.edu/ie/
  • University of Maryland
    • Video analysis in OR and ED
    • Alarms redesign
    • HFE and BME key to DCERPS
    • http://www.safetycenter.umm.edu/
academia cont
Academia (cont.)
  • University of Virginia
    • Laparscopic Cholecystectomy – training, etc.
    • http://www.sys.virginia.edu/hci/
  • University of Toronto
    • PCA pumps
    • Procurement
      • Savings from one device investigation paid for expense of HF Expert for one year
    • http://www.mie.utoronto.ca/labs/cel/research/pca.html
    • http://www.mie.utoronto.ca/labs/cel/
bibliography
Bibliography
  • Gosbee JW. Introduction to the human factors engineering series. Joint Commission Journal on Quality and Safety. 2004; 30(4): 215-219.
  • Gosbee JW, Anderson T. Human factors engineering design demonstrations can enlighten your RCA team. Quality & Safety in Health Care. 2003; 12: 119-121. http://qhc.bmjjournals.com/cgi/content/abstract/12/2/119?etoc
  • Dumas, J. and Redish, G. (1993). A Practical Guide to Usability Testing. Norwood, NJ: Ablex.
  • Nielsen, J. (1993) Usability Engineering. Boston: AP Professional.
  • Rubin, J. (1994). Handbook of Usability Testing. New York: John Wiley & Sons, Inc.