Human Factors Engineering and Patient Safety

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

7. Human Factors Model • Psychomotor • Hand • - Feet • Input Devices • Buttons • - Foot pedal INTERFACE Senses - Vision - Hearing Output - Color display - Sound

8. Radar Scope to Detect “enemy” ships

9. ECG Signal (Telemetry) Monitoring

10. Performance Graph (curve) 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

11. Performance Graph (curve) 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

12. How can we move the curve upwards? 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

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. Medical Device Correlation • What does this phrase mean  “Telemetry Off” • To a novice? To an expert?

15. What is this regulator used for? • Write your answer down on paper

16. Demonstration: Stroop Test Row 1 Row 2 Row 3

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. 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. 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. 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. 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. 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

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. 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. 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. Learned intuition examples • Secretaries using computers • Other examples?

27. Human factors engineering and patient safety case studies • Code Cart drawer • PCA pump

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

29. Code Cart Drawer Fifth VersionRange = :55-1:25 min, Avg=1:08 Note the lack of labels for each spot

30. PCA: Interface Redesign – Univ. Toronto ExistingDesign New Design

31. Legend Decision Message-guided Action Action PCA: Programming Sequence Redesign Existing Design New Design

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. 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. 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. 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. 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

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. 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. Take a look around us

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. 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. Consistency • Location of controls • Typewriter • Brake pedal in car • Defibrillator

43. Consistency: Examples from daily life

44. Consistency: Clinical Example • Your Examples? – testimonials

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. Real world examples

47. Clinical Example – Defibrillator

48. Feedback – your examples

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. Clinical Example #1 – Cardiac Monitor This piece of tape says “On/Off”