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1 Human Factors Engineering and Patient Safety Michigan Health & Safety Coalition – Annual Conference John Gosbee, MD, MS VA National Center for Patient.

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Presentation on theme: "1 Human Factors Engineering and Patient Safety Michigan Health & Safety Coalition – Annual Conference John Gosbee, MD, MS VA National Center for Patient."— Presentation transcript:

1 1 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

2 PSIC - January 2004 2 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

3 PSIC - January 2004 3 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

4 PSIC - January 2004 4 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

5 PSIC - January 2004 5 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

6 PSIC - January 2004 6 HFE Quiz (cont.) Which blue knob controls the dial on the right? Why ? Control Panel

7 PSIC - January 2004 7 Human Factors Model Senses - Vision - Hearing Psychomotor - Hand - Feet Input Devices - Buttons - Foot pedal Output - Color display - Sound INTERFACEINTERFACE

8 PSIC - January 2004 8 Radar Scope to Detect “enemy” ships

9 PSIC - January 2004 9 ECG Signal (Telemetry) Monitoring

10 PSIC - January 2004 10 100% 90% 80% 70% Time (hours) 1234 Performance Performance Graph (curve)

11 PSIC - January 2004 11 100% 90% 80% 70% Time (hours) 1234 Performance Performance Graph (curve)

12 PSIC - January 2004 12 How can we move the curve upwards? 100% 90% 80% 70% Time (hours) 1234 Performance

13 PSIC - January 2004 13 Another Demonstration with a Patient Safety Twist Look at the next slide Count the number of words in the paragraph that are repeated

14 PSIC - January 2004 14 Medical Device Correlation What does this phrase mean  “Telemetry Off” To a novice? To an expert?

15 PSIC - January 2004 15 What is this regulator used for? Write your answer down on paper

16 PSIC - January 2004 16 Demonstration: Stroop Test Row 1 Row 2 Row 3

17 PSIC - January 2004 17 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.

18 PSIC - January 2004 18 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

19 PSIC - January 2004 19 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

20 PSIC - January 2004 20 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.

21 PSIC - January 2004 21 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)

22 PSIC - January 2004 22 Healthcare “Systems” Range from the Simple to Complex Syringe, catheter bag and its tubing O 2 cylinder, ECG machine, IV pump Code cart, anesthesia work station Hospital computer system MRI control room and suite ICU, ED, OR

23 PSIC - January 2004 23 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

24 PSIC - January 2004 24 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

25 PSIC - January 2004 25 HFE and Patient Safety Lesson Simple steps never are Learned intuition and assumptions –Stereotypes –Metaphors Iterative testing of instructions to work the bugs out

26 PSIC - January 2004 26 Learned intuition examples Secretaries using computers Other examples?

27 PSIC - January 2004 27 Human factors engineering and patient safety case studies Code Cart drawer PCA pump

28 PSIC - January 2004 28 Baseline Drawer ( “ Laundry hamper ” ) Range = 2:43-3:58 min, Avg=3:07 min Note the multiple orientations

29 PSIC - January 2004 29 Code Cart Drawer Fifth Version Range = :55-1:25 min, Avg=1:08 Note the lack of labels for each spot

30 PSIC - January 2004 30 PCA: Interface Redesign – Univ. Toronto Existing DesignNew Design

31 PSIC - January 2004 31 PCA: Programming Sequence Redesign Existing DesignNew Design Decision Message-guided Action Action Legend

32 PSIC - January 2004 32 Usability Evaluation of a PCA Pump: Measurements Programming Errors Measured –Quantity –Severity Performance Measured –Programming Time –Task completion time Mental Workload Ratings  NASA-TLX

33 PSIC - January 2004 33 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

34 PSIC - January 2004 34 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

35 PSIC - January 2004 35 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

36 PSIC - January 2004 36 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 8.Good Error Messages 9.Help and Documentation 10.Readable and understandable labels and warnings

37 PSIC - January 2004 37 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

38 PSIC - January 2004 38 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

39 PSIC - January 2004 39 Take a look around us

40 PSIC - January 2004 40 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?

41 PSIC - January 2004 41 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

42 PSIC - January 2004 42 Consistency Location of controls –Typewriter –Brake pedal in car –Defibrillator

43 PSIC - January 2004 43 Consistency: Examples from daily life

44 PSIC - January 2004 44 Consistency: Clinical Example Your Examples? – testimonials

45 PSIC - January 2004 45 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

46 PSIC - January 2004 46 Real world examples

47 PSIC - January 2004 47 Clinical Example – Defibrillator

48 PSIC - January 2004 48 Feedback – your examples

49 PSIC - January 2004 49 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

50 PSIC - January 2004 50 Clinical Example #1 – Cardiac Monitor This piece of tape says “On/Off”

51 PSIC - January 2004 51 Clinical Example #2 – Syringe

52 PSIC - January 2004 52 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

53 PSIC - January 2004 53 Your clinical examples

54 PSIC - January 2004 54 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

55 PSIC - January 2004 55 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

56 PSIC - January 2004 56 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 http://www.devicelink.com/mddi/archive/02/05/004.html VA Web Site http://www.patientsafety.gov/hf.htmlhttp://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 ”)

57 PSIC - January 2004 57 Web Sites (more) Human Factors Society (HFES) –Website:http://www.hfes.org/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.htmlhttp://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/http://sigchi.org/ –Local Chapters of SIGCHI

58 PSIC - January 2004 58 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/

59 PSIC - January 2004 59 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/

60 PSIC - January 2004 60 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 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.


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