patient safety and human factors engineering spring2006

Patient Safety and Human Factors Engineering

Anne Arundel Community CollegeArnold, MDCarolyn Jenkins MSN, RNSpring, 2006

Adapted from John Gosbee, MD, MS

VA National Center for Patient Safety

John.Gosbee@med.va.gov www.patientsafety.gov

Describe human factors model. Examine the use of Human Factors

Engineering (HFE) principles as a problem-solving approach to identify and control patient safety hazards.

Perform a usability study with a simple product using human factors engineering principles.

Propose improvements to the product to increase usability and prevent potential adverse events and close calls.

OBJECTIVES

Kyle, L. (2005). First place winner. The faces of caring: Nurses at work. 105,6.

Designing systems devices, software, and tools to fit human capabilities and limitations

Using methods to gather unique information on: Hidden needs of the

end-user Unexpected

interactions between the system and the end-user

Taking advantage of knowledge bases about human-system interaction

What is 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.

Why should we care about good "Human Factors"?

Human Factors applied early in the design process results in:

• Increases in productivity, improved performance, and greater user satisfaction;• Reduced need for training, system maintenance, and user support;• Reduction in errors, incidents/accidents, and overall costs.

Improved system design results in reduced costsand improved productivity/performance.

http://www.hf.faa.gov/webtraining/index.htm

FEDERAL AVIATION ADMINISTRATION

http://www.baddesigns.com/

Bad Design Kills

Human Factors Model

Senses- Vision - Hearing

Psychomotor- Hand

- Feet

Input Devices- Buttons

- Foot pedal

Output- CRT - Sound

INTERFACE

Radar Scope to Detect “enemy” ships

100%

90%

80%

70%

Time (hours)1 2 3 4

Perf

orm

an

ce

Performance Graph (curve)

100%

90%

80%

70%

Time (hours)1 2 3 4

Perf

orm

an

ce

Performance Graph (curve)

How can we move the curve upwards?

100%

90%

80%

70%

Time (hours)1 2 3 4

Perf

orm

an

ce

Demonstration: Stroop Effect

Row 1

Row 2

Row 3

Now, State the Color of the Text as Fast as You Can…

Red

Red

Red Blue

Blue

BlueYellow

Yellow

Yellow

Green

Green

Green

Row 1

Row 2

Row 3

Again, State the Color of the Text as Fast as You Can…

Red

Red

Red Blue

Blue

BlueYellow

Yellow

Yellow

Green

Green

Green

Row 1

Row 2

Row 3

Count the number of times

the word “RED” appears in this example.

“Tell the nursing student to attach the oxygen mask and tubing to the green spigot”

For further info, see http://faculty.washington.edu/chudler/words.html#seffect J. Ridley Stroop (1935) Studies of Interference in Serial Verbal Reactions. Journal of Experimental Psychology, vol 18, 643-662

Patient Safety Correlation

Knee-jerk vs. HFE-based Remedy

Make “sure” to use the correct color Adaptor!?

Better

HFE ExamplePatient Controlled Analgesia (PCA) Pump Redesign

Existing Design New Design

Lin, L., R. Isla, K. Doniz, H. Harkness, K.J. Vicente, and D.J. Doyle, 1998. Applying HumanFactors to the Design of Medical Equipment: Patient-controlled Analgesia. Journal of ClinicalMonitoring and Computing 14: 253-263.

PCA: Programming Sequence Redesign

Existing Design New Design

DecisionMessage-guided ActionAction

Legend

User population

Tested with 2 user populations: Novice users

Nursing students n=12

Expert usersRecovery Room Nurses n=12

Usability Evaluation of a PCA Pump: Measurements

Programming Errors Measured Quantity Severity Subtask classification

Performance Measured Programming Time Task completion time Subtask completion time

Mental Workload Ratings NASA-TLX

Subjective Preference Questionnaire

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

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

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

"Don't worry--it always beeps when you do that!"

Multi-Channel Infusion Pump

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? Layout and structure of

The room The overall environment

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)

Take home points:

Be aware of and take extra precautions during vulnerable times-( tired, hungry, new equipment or procedures)

Ask manufacturer for usability studies. Evaluate new products and equipment so the USER

voice is heard. Trust yourself first. If the machine is giving you data

that does not support your patient assessment, try another machine or test the machine on yourself.

Avoid work arounds. If some part of the machine is not working, send it to bio med.

Volunteer to work on product and equipment selection committees so the USER voice is heard.

HFE Exercise: Groups of 3-4

One person as Director Remind equipment user to think aloud. Prevent others in the group from assisting the equipment user. Lead subsequent discussion.

One person as equipment user What is it? What is it used for? How is it used? Use the device in the way you think it should be used

2 – 3 Observers Document actions, what is said, swear words, facial expressions

etc.

Human Factors Engineering

Website of Human Factors Design Problems Case Studies. http://www.baddesigns.com/ Examples of things that are hard to use because they do not follow human factors principles.

Human Factors and Ergonomics Society. The main professional organization in the United States. www.hfes.org

Food & Drug Administration Human Factors Section. Several documents about medical devices, errors, and the design process (e.g., “Do it By Design”) www.fda.gov/cdrh/humanfactors.html

FAA On-line Tutorial on Introduction to HFE. Good and free interactive site to see depth and breadth in pretty good format. See www.hf.faa.gov/Webtraining/Intro/Intro1.htm

Stroop Color Demonstration and other Cognitive Psychology Demos. Eric Chudler. University of Washington. faculty.washington.edu/chudler/words.html

Kitaoka, A. and H. Ashida: Phenomenal Characteristics of the Peripheral Drift Illusion. Vision Vol. 15, No.4, 261-262. 2003 http://www.psy.ritsumei.ac.jp/~akitaoka/PDrift.pdf

Agency for Healthcare Research and Quality http://psnet.ahrq.gov Center for American Nurses. Culture of Safety. On line Continuing Education offering

http://www.centerforamericannurses.org/can/news/safetyce.htm Institute For Safe Medication Practices 1800 Byberry Road, Suite 810, Huntingdon

Valley, PA 19006 http://www.ismp.org/ Joint commission International Center for patient safety Peter Angood MD Chief Patient

Safety Officer Maryland Patient Safety Center 6820 Deerpath Rd. Elkridge, MD 21075 –Mary

Hofbauer Brown mhbrown@mhaonline.org National Center for Patient Safety. http://www.patientsafety.gov Linda Williams RN

linda.williams7@med.va.gov National Coordinating Council for Medication Error Reporting and Prevention

http://www.nccmerp.org Open Directory http://dmoz.org/Health/Public_Health_and_Safety/Patient_Safety/ National Patient Safety Foundation: www.npsf.org National Quality Forum: www.qualityforum.org American Nurses Association Nursing World Patient Safety and Advocacy Website

http://www.nursingworld.org/patientsafety/

Web sites for Patient Safety

References:

Kohn, L., Corrigan, J. & Donaldson, M. (Eds.) (2000). To err is human. Building a safer Health care system. Washington, DC: National Academy Press.

Lin, L., R. Isla, K. Doniz, H. Harkness, K.J. Vicente, and D.J. Doyle, (1998). Applying Human Factors to the Design of Medical Equipment: Patient-controlled Analgesia. Journal of Clinical Monitoring and Computing 14: 253-263.

Page, A. (Ed.).(2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press.

Veterans Administration National Center for Patient Safety. Patient Safety Curriculum Toolkit. Available at http://www.patientsafety.gov/PSC/PSCurric.html

Vicente, K. (Summer 2002). Professional ethics as a systems problem: A case study for teaching. Cognitia. 6,1. Retrieved September 2005 from http://cedm.hfes.org/Cognitia_6.pdf