patient safety and human factors engineering spring2006
DESCRIPTION
The second Power Point in a 3 part seminar for nursing students during their medical surgical clinical rotation. Adapted from Dr. John Gosbee MD, MS VA National Center for Patient Safety Tool Kit Available at www.patientsafety.gov in 2005.TRANSCRIPT
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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
[email protected] www.patientsafety.gov
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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
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Kyle, L. (2005). First place winner. The faces of caring: Nurses at work. 105,6.
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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?
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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.
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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
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http://www.baddesigns.com/
Bad Design Kills
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Human Factors Model
Senses- Vision - Hearing
Psychomotor- Hand
- Feet
Input Devices- Buttons
- Foot pedal
Output- CRT - Sound
INTERFACE
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Radar Scope to Detect “enemy” ships
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100%
90%
80%
70%
Time (hours)1 2 3 4
Perf
orm
an
ce
Performance Graph (curve)
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100%
90%
80%
70%
Time (hours)1 2 3 4
Perf
orm
an
ce
Performance Graph (curve)
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How can we move the curve upwards?
100%
90%
80%
70%
Time (hours)1 2 3 4
Perf
orm
an
ce
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Demonstration: Stroop Effect
Row 1
Row 2
Row 3
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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
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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
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Count the number of times
the word “RED” appears in this example.
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“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
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Knee-jerk vs. HFE-based Remedy
Make “sure” to use the correct color Adaptor!?
Better
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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.
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PCA: Programming Sequence Redesign
Existing Design New Design
DecisionMessage-guided ActionAction
Legend
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User population
Tested with 2 user populations: Novice users
Nursing students n=12
Expert usersRecovery Room Nurses n=12
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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
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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
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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
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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
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"Don't worry--it always beeps when you do that!"
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Multi-Channel Infusion Pump
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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
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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)
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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.
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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.
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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
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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 [email protected] National Center for Patient Safety. http://www.patientsafety.gov Linda Williams RN
[email protected] 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
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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