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Design for Improved Patient SafetySociotechnical Systems Design

and Resilience Engineering

Ida BodinCamilla Fröjd

Anders Jansson

Intensive care

Automation failures

Poor control

Public safety

Work distributed spatially

Work distributed over time

Disturbances

Communication needs

Presented information might be erroneous

Cognitively demanding to interact with abstract UI’s

Many actors

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Emphasizing responsibility on management level

Emphasizing individuals’ responsibility

Emphasis onblaming

Emphasis onnon-blaming

Nuclear power safety

Aviation safety

Work environment safety

Patient safety

Environment protection

Product safety

Construction safety

Railway safety

Maritime safety

Service sector safety

Traffic & Automotive safety

Water protection

Electrical safety

Fire safety

Ref: Strömgren, Harms-Ringdahl & Gell. (2008).

Organizational safety cultures

Agenda

What design challenges are there, and how can we understand them from a patient safety perspective?

What design challenges did we go for in this SPARC-project, and why?

What is unique in our approach, and what methods do we use? Results from the field studies – so far

Sociotechnical systems design and holistic work support Resilience engineering and proactive safety

Future work

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Haverikommissionen pekar på brister i hjärtintensivvården För första gången har Statens haverikommission utrett ett dödsfall inom sjukvården. Det handlar om en kvinna som dog av ett hjärtstopp efter att ha placerats som satellitpatient på en hjärtintensivvårdsavdelning.

– Vi hade uppmärksammat att det fanns säkerhetsbrister och att det var många händelser inom sjukvården. Att det blev just dödsfallet vid Karolinska universitetssjukhuset var en tillfällighet och berodde på att fallet blev medialt uppmärksammat (Urban Kjellberg, Statens Haverikommission).

2013;110:CLY4

Swedish Accident Authority Report

The Authority concluded that factors at two different levels of the organization contributed to the evolvement of the accident.

• Latent errors at the blunt-end resulted in unclear instructions regarding the telemetric surveillance equipment, in turn creating uncertain conditions during transfer between divisions as well as when shifting staff. Despite the lack of clear instructions staff was forced to decide by themselves, since time did not allow consultation with colleagues or management.

• Event-related errors at the sharp-end. The staffs’ use of the telemetric surveillance equipment was not in accordance with the instructions since the alarm system resulted in a number of documented false alarms. This in turn resulted in reduced attention among staff, with the consequence that a correct alarm was rejected.

From: Bodin, Fröjd & Jansson. 2016. Work domain analysis of an intensive careunit: An Abstraction Hierarchy based on a bed-side approach.

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Individual systems for specific tasks

Level 1: Interaction design

“The interface I use when I interact with a specific system ”

“All the systems I use in an everyday work situation and the systems I share with my colleagues”

Systems that make up the complete work environment for an individual user and the whole staff

Level 2: Sociotechnical systems design

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Level 3: Resilience engineering

“Me as part of a complete sociotechnical system caring for the patient”

Systems on organizational level

Three human factors challenges

• Interaction design: Inadequate design of applications and apparatus

• Sociotechnical systems design: Insufficient integration of medical-technical equipment

• Resilience engineering: Limited follow-up on non-conformance reports

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Resilience engineering –Limited or no follow-up onnon-conformance reports

Sociotechnical systems design –Insufficient integration

SPARC – Two challenges to go for

Inadequate interaction design

Our approaches

CWA –

Cognitive Work Analysis

GMOC –

Goals, Models, Observability & Control

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General method I:

Cognitive Work Analysis (CWA)

Olsson, E. & Jansson, A. (2005). Interacting with Computers, 17, 147-166.Jansson, A., Olsson, E. & Erlandsson, M. (2006). Cognition, Technology and Work, 8, (1), pp.41-49.Olsson, E. & Jansson, A. (2006). Behaviour & Information Technology, 25, 37-64.Bodin, I., Axelsson, A., Vännström, J. & Jansson, A. (2016). Theoretical Issues in Ergonomics Science (submitted).Bodin, I, Fröjd, C. & Jansson, A. (2016). In D. de Waard, K.A. Brookhuis, A. Toffetti, A. Stuiver, C. Weikert, D. Coelho, D. Manzey, A.B. Ünal, S. Röttger, and N. Merat (Eds.), Proceedings of the Human Factors and Ergonomics Society Europe Chapter 2015 Annual Conference. ISSN 2333-4959 (online).

Work Domain Analysis (WDA)An abstraction hierarchy

Describing a work domain independent of tasks, actions, situations and persons

The constraints shaping the work

Functional Purpose

Values and priority measurements

Purpose Related Functions

Object Related Processes

Physical Objects

Why

?

How

?

(Rasmussen, 1994; Vicente, 1999)

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Video recordings of the nurses’ work

Colleagues verbalize during video playback

Compare withother data

General method II:

Knowledge elicitations

Jansson, A., Olsson, E. & Erlandsson, M. (2006). Cognition, Technology and Work, 8, (1), p.41-49.Erlandsson, M. & Jansson, A. (2007). Behaviour & Information Technology, 26, (6), p.535-543.Erlandsson, M. & Jansson, A. (2013). Cognition, Technology and Work, 15, 239-254.Jansson, A., Erlandsson, M., Fröjd, C. & Arvidsson, M. (2013). Interact, HWI Workshop, pp. 35-40.Jansson, A., Erlandsson, M. & Axelsson, A. (2015). Theoretical Issues in Ergonomics Science, 16, (5), 474-494.

The first challenge

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Example from train traffic control

Before

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After

Decision relevant information?No Yes

Abstraction hierarchy

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Abstraction hierarchy

Results

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Results

Results

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How to use the results?

The abstraction hierarchy contains information requirements and functions useful for design challenges

Ecological Interface Design (EID) is an approach for interface design for complex sociotechnical systems (process control, aviation, medicine)

The goal is to make constraints and complex relationships in the work environment evident to the user - supports problem solving

(Rasmussen & Vicente, 1989)

Kno

wle

dge

/ Abi

lity

Problem StructureGeneral Deep

Gen

eral

Spe

cific

Coherence or Intent-Driven

Correspondence or Law-Driven

Ecological Interface Design

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The second challenge

Develop proactive safety procedures in order to enhance the organizational safety culture

The goal is to develop a standardized method for barrier analysis and to avoid risky situations

Develop the collegial verbalization method to discuss ‘bed-side’ work situations with nurses

Result Production

Safety Economy

Trust & Health

Goals

Efficiency

Organization Methods Competence Structure System

Organizational culture

Norms Ideas Policies Attitudes Strategies

Measures

Basics

Safety culture

MethodCollegial verbalization and

‘conspective’ protocols

Video films from “bed-side”

Colleagues verbalize during video-playback

Comparisons with other sources of data

3 situations and focus on different events, e.g.: Wrong medication to patient Central Venous Catheter pulled out Endotracheal Tube out of position

Analyses from a Human-Technology perspective, with focus on barriers

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Method

Collegial verbalizations in the form of ‘conspective’ protocols with nurses to be able to analyse risky events and behaviours (non-conformances)

All together three subject matter experts (two enrolled nurses and one staff nurse)

All together six verbalization sessions based on video-recordings from routine work tasks and situations

This resulted in three retrospective protocols, and three ‘conspective’ protocols

The plan is to include more situations and nurses

Preliminary resultsCategories of existing barriers

Technical Administrative Organizational Staff expertise

SurveillanceSystems

Check lists Roles & Responsibility

Monitoring equipmentfunction and condition

Alarm systems and alarm levels

Procedures Routines Checking on patients’ status

Physical measures

Labelling measures Collegial support

Overall situation assessment

Power supply Medical protocols

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Representation Knowledge

Interpretation

Work Domain

Value

The role of the designer is to create representations and by that facilitating for the user to carry out his/her work

The triadic approach to systems design

Reality Interface User

System and Interface Designers

• Insufficient integration of medical-technical equipment → Application to FORTE

– Enhanced sociotechnical systems design concept – holistic design

• Limited follow-up on non-conformance reports → Application to AFA, FORMAS

– Collegial collaboration for proactive safety – a standardized method for barrier analysis

• Strengths

– The bed-side perspective is unique

– The CV-method offers unique possibilities

– Theoretical models behind interaction design

Future work