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Incorporating Human Factors Engineering into Risk Reduction Strategies

Incorporating Human Factors Engineering into Risk Reduction Strategies. Laura Lin Gosbee Human Factors Engineer. My Background. Human Factors University of Toronto – Institute of Biomedical Engineering/ Dept. of Mechanical & Industrial Engineering

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Incorporating Human Factors Engineering into Risk Reduction Strategies

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  1. Incorporating Human Factors Engineering into Risk Reduction Strategies Laura Lin Gosbee Human Factors Engineer Laura Lin Gosbee 10/30/03

  2. My Background • Human Factors • University of Toronto– Institute of Biomedical Engineering/ Dept. of Mechanical & Industrial Engineering • Northrop Grumman Corporation – Information Technology Sector • Applied R&D • Systems Design & Evaluation • Areas of Application • Health Care - Toronto Hospital, Toronto, Canada • Nuclear Power- Westinghouse, Pittsburgh, PA • Military - Wright-Patterson Air Force Base, Dayton, OH Laura Lin Gosbee 10/30/03

  3. Overview • Human Factors Approach • What is it? • What can it be applied to? • How is it useful to your hospital? • Applying Human Factors Engineering • Proactive and Reactive Strategies • Methods and Tools • Human Factors case studies Laura Lin Gosbee 10/30/03

  4. Human Factors - What is it? • Human Factors (HF) is the study of human capabilities and limitations and the application of that knowledge to the design of systems Laura Lin Gosbee 10/30/03

  5. What can it be applied to? Home Medical Device Spectrum of Complexity Control Room Defibrillator/Pacemaker ASO Policies MRI safety Electronic Patient Records Crash Carts CPOE Automated Dispensing Device Laura Lin Gosbee 10/30/03

  6. What can it be applied to? • Equipment • Software • Paper Forms • Policies, Protocols, Procedures • Workspace Layout • Training & Education Analyze Design Test What’s the commonality? • All involve human-system interaction Laura Lin Gosbee 10/30/03

  7. How is it useful to your hospital? • Add usability data to procurement decisions • Augment RCA and FMEA processes by: • Relying less on guess work or brain-storming to identify root causes or failure modes • Expanding actions from RCAs beyond: • be more careful, more training, more policies, more rules to follow policies Laura Lin Gosbee 10/30/03

  8. QualityHealthcare.org “Fundamental insights about human error and the nature of accidents …shifts attention away from the fault of individuals to the larger contributing factors, often hidden and almost always out of their control.” Laura Lin Gosbee 10/30/03

  9. Example of Finding Root Causes • Fighter planes before WWII • Problem: planes crashing on night sorties, explanation elusive • “Simulate” by putting blanket over cockpit • No lighting to see gauges, lack of other visual cues • Pilot error? No. HF design issue! Laura Lin Gosbee 10/30/03

  10. Key Messages • Not all HF problems are as seemingly obvious • Errors can be latent: “dormant” until night-time sorties • Example of human limitation: can’t see in the dark • Can’t always overcome with more training • Policies, e.g., permitting only daytime sorties, don’t tackle the problem • Most effective solution is in design: add cockpit lighting Laura Lin Gosbee 10/30/03

  11. Radar Scope to Detect Enemy Ships Laura Lin Gosbee 10/30/03

  12. Performance Graph (curve) 100% 90% 80% 70% Performance 1 2 3 4 Time (hours) Laura Lin Gosbee 10/30/03

  13. How can we move the curve upwards? 100% tactile feedback auditory feedback 90% blinking 80% colour 70% shape Performance 1 2 3 4 Time (hours) Laura Lin Gosbee 10/30/03

  14. Another Example: • New house, new faucets • Which way do you turn them? D B C A Laura Lin Gosbee 10/30/03

  15. Expectations and Biases • Operation does not match expectations • No visual cues on how to operate • Negative transfer of training • Inappropriate mental model: Lever faucets B Laura Lin Gosbee 10/30/03

  16. In This Example • Outcome not serious • Finite number of ways to operate • Danger of trial and error is not high • Not always the case In health care: • systems not necessarily as forgiving • not limited to a few ways of using it • trial and error not safe or allowed Laura Lin Gosbee 10/30/03

  17. Example: PCA pump • Nurses program pump: drug concentration, dose, 4 hour limit, etc. • Programming screen: 4 hour limit set? Yes or no? • Does it mean: • “have you already set it?” • “do you want to set it?” • At one hospital, for the first year, nurses interpreted as a) and answered “no” Laura Lin Gosbee 10/30/03

  18. Spend the next few minutes thinking of an example that you experienced (or saw happen to someone else) • share it with the person next to you… Laura Lin Gosbee 10/30/03

  19. When is HF Applied? • HF Methods can be applied to PROACTIVE and REACTIVE risk reduction strategies Laura Lin Gosbee 10/30/03

  20. Proactive Strategies • When you want to keep “latent errors” from creeping into your hospital, incorporate HF when: • Purchasing new products • Designing and developing: • in-house products or processes • training & education programs • workspace layout Laura Lin Gosbee 10/30/03

  21. Proactive Strategies • Guide development of in-house products: • policies/protocols, paper forms, software, devices, etc. • Test/Validate before implementation • Obtain usability data to compare products before purchasing • Conduct a prospective risk assessment (FMEA) of systems Laura Lin Gosbee 10/30/03

  22. Targets for Proactive Strategies • Equipment (syringes, automated dispensing devices) • Connections for IV tubing, Oxygen • Drug labels and storage • Policies, procedures and protocols (new and old) • Software (CPOE, patient records) • Paper forms (order forms, checklists, warning signs, policy manuals) Laura Lin Gosbee 10/30/03

  23. Reactive Strategies • When you have to solve existing problems, incorporate HF when: • Investigating adverse events Laura Lin Gosbee 10/30/03

  24. Reactive Strategies • Use HF to help identify vulnerabilities or contributing factors in an RCA • Use HF methods when developing and validating RCA actions Laura Lin Gosbee 10/30/03

  25. Targets for Reactive Strategies • Equipment (syringes, automated dispensing devices) • Connections for IV tubing, Oxygen • Drug labels and storage • Policies, procedures and protocols (new and old) • Software (CPOE, patient records) • Paper forms (order forms, checklists, warning signs, policy manuals) Laura Lin Gosbee 10/30/03

  26. Sampling of HF Methods and Tools • HF Testing • Human-in-the-loop • User-centered testing • Usability Testing • Cognitive Walkthrough • Heuristic Evaluation • Simulator Testing • (part-task, full-scale) • HF Analysis • Task Analysis • Field Observations • Interviews • Bench Tests • Cognitive Walkthrough • Heuristic Evaluation • HF Design • HF Design Principles • Results from Analysis phase • Standards & Guidelines Laura Lin Gosbee 10/30/03

  27. What can it be applied to? • Equipment • Software • Paper Forms • Policies, Protocols, Procedures • Workspace Layout • Training & Education Analyze Design Test Laura Lin Gosbee 10/30/03

  28. GUI Screens of each Subtask Decision/Action Diagrams for each GUI Screen Subtasks Tasks Task 1 D1 screen 1 Subtask 1 D2 D3 D4 D5 D6 screen 2 screen 3 Subtask 2 Task 2 A1 A2 A3 A4 A5 A6 screen 4 screen 5 screen 6 Subtask 3 D7 D8 D9 D10 D11 screen 7 screen 8 screen 9 Task 3 A10 A7 A8 A9 A11 A12 screen 10 screen 11 Task 4 A14 A13 screen 12 HF Analysis (TASK FLOW) (INFO FLOW) Detailed Level Abstract Level Laura Lin Gosbee 10/30/03

  29. GUI Screens of each Subtask Decision/Action Diagrams for each GUI Screen Subtasks Tasks Task 1 D1 screen 1 Subtask 1 D2 D3 D4 D5 D6 screen 2 screen 3 Subtask 2 Task 2 A1 A2 A3 A4 A5 A6 screen 4 screen 5 screen 6 Subtask 3 D7 D8 D9 D10 D11 screen 7 screen 8 screen 9 Task 3 A10 A7 A8 A9 A11 A12 screen 10 screen 11 Task 4 A14 A13 screen 12 Correct Decision/Action Path Deviations from correct Decision/Action Path HF Analysis Laura Lin Gosbee 10/30/03

  30. HF Design Old Task Structure Redesigned Task Structure Laura Lin Gosbee 10/30/03

  31. HF Testing • What can be tested? • Devices • Software • Forms • Processes • Policies • Procedures, etc. • Testing works just as well for written material as it does for devices! • Products from policy/protocols: • Instruction material • Cognitive aids (cheat sheets) • User manuals • Memos • Alerts or Warning Signs Laura Lin Gosbee 10/30/03

  32. HF Testing • Example - Protocol to be Tested: • Readability • Content • Layout • Usability of associated material: • drug labels, vials, • tubing, connections, • IV pumps, cartridges • storage & retrieval Protocol for Preparing Medication Step 1 - Step 2 - Step 3 - Step 4 – Etc. Useful? Usable? Learnable? Accepted? Laura Lin Gosbee 10/30/03

  33. HF Methods & Tools A few of many… • Cognitive Walkthrough • Heuristic Evaluation • Usability Testing Laura Lin Gosbee 10/30/03

  34. 1. Cognitive Walkthrough Preparation: • Recruit end “users” • Develop “scenarios” & “tasks” Methodology • Participants think aloud as they “walk” you through using a system/protocol • Use a variety of scenarios • Ask them to verbalize any decision or mental step • Record difficulties Laura Lin Gosbee 10/30/03

  35. 2. Heuristic Evaluation Preparation • HF design principles • Design guidelines/standards (AAMI/ANSI) • Guidelines for medical applications, e.g., Do it by Design, Write it Right (FDA) Methodology • Essentially a usability audit • Evaluate against guidelines & design principles • Evaluate both form (e.g., visual design) and content Laura Lin Gosbee 10/30/03

  36. Human Factors Engineering Guidelines • Overall Human Factors • Feedback and Visibility of System Status • Consistent Model or Metaphor • Functionality of Controls • Displayed Messages • Recognition and Recovery from Errors • Minimizing User Memory Load • Readable and understandable labels and warnings Laura Lin Gosbee 10/30/03

  37. Triggering Questions* * Human Factors Tool developed by: John Gosbee & Laura Lin Gosbee Feedback and Visibility of System Status • When you try to do things, how do you know you are successful? · • Do you know what the device is doing at any given moment? • If you are distracted, can you tell immediately where you've left off? • If you handed the device to someone, does it take them long to figure out where you've left off and what the device is doing? Laura Lin Gosbee 10/30/03

  38. Triggering Questions* * Human Factors Tool developed by: John Gosbee & Laura Lin Gosbee Functionality of Controls • Is it obvious what each button or switch will do? • Do they work the same in different circumstances? • Do some buttons/switches look too similar to others? • Are they grouped/located in a logical manner? • Are some controls more critical than others? • If so, how are they differentiated from other controls? Laura Lin Gosbee 10/30/03

  39. Triggering Questions* * Human Factors Tool developed by: John Gosbee & Laura Lin Gosbee Displayed Messages • Is the message display big enough? • Can you understand the messages? • Is the language simple and natural? • Is the information useful? • Do you need more information? • Is it displayed long enough for it to be useful? Laura Lin Gosbee 10/30/03

  40. 3. Usability Testing Preparation • Recruit end users • Develop “scenarios” and “tasks” • Select test site • Performance measures (e.g., errors, time to recover from errors, mental workload) • Test plan (experimental design & protocol) Methodology • Generally, participants are asked to carry out a ‘task’ while performance data is collected unobtrusively Laura Lin Gosbee 10/30/03

  41. Performance Goals Performance Benchmarks Examples: • 90% people using it “cold” can do it without errors • 80% people interpreting the policy can understand the rationale or implications Laura Lin Gosbee 10/30/03

  42. Example: Epinephrine Auto-Injector • Epinephrine used for Anaphylaxis • Auto-injector administers epinephrine • Device is used in emergency situations Laura Lin Gosbee 10/30/03

  43. A Quick and Dirty Usability Test • Design Goal (performance goal): lay person can use it in an emergency with no prior training • Volunteer with no previous experience with auto-injectors • Using a “trainer” – NO NEEDLES! Laura Lin Gosbee 10/30/03

  44. Scenario • I just ate some cookies with traces of peanuts • I am going into anaphylactic shock… I’ve stopped breathing • You are alone with me and found my auto-injector • Need to administer it quickly before the unthinkable… Laura Lin Gosbee 10/30/03

  45. Lessons • Design helps/hinders human performance • Environment of use specifies performance requirements (benchmarks) • lay person, little or no training, timeliness *Gosbee LL. Nuts! I can’t figure out how to use my life-saving auto-injector: Human factors issues associated with an epinephrine auto-injector. Joint Commission Journal on Quality and Safety (in press). Laura Lin Gosbee 10/30/03

  46. Case Study: HF analysis of “confusion” • Hospital in Salt Lake City had many issues with code teams • One issue they observed many times was confusion and delay with medication drawer retrieval • They performed usability (HFE) testing with • 9-11 end-users • Retrieving 10 medications • Five versions of the drawer *McLaughlin RC. Redesigning the crash cart: usability testing improves one facility's medication drawers. Am J Nurs. 2003;103(4):64A,64D,64G-64H. Laura Lin Gosbee 10/30/03

  47. Baseline Drawer (“Laundry hamper”)Range = 2:43-3:58 min, Avg=3:07 min Laura Lin Gosbee 10/30/03

  48. Code Cart Drawer Fifth VersionRange = :55-1:25 min, Avg=1:08 Note the lack of labels for each spot Laura Lin Gosbee 10/30/03

  49. Case Study: PCA pump • University of Toronto and Toronto General Hospital • 1993: nurse complaints about “new device”: PCA pumps • HF study: • HF analysis • redesign • user testing Laura Lin Gosbee 10/30/03

  50. PCA: Interface Redesign ExistingDesign New Design Laura Lin Gosbee 10/30/03

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