usability & human factors unit 10b designing for safety

Usability & Human Factors

Unit 10bDesigning for Safety

Woods and Colleague: Resilience Engineering

Component 15/Unit 10bHealth IT Workforce Curriculum

Version 1.0/Fall 20102

Woods and Colleague:Challenger Analysis



‘Failure of Foresight’



Woods and Colleague:Challenger Analysis (con’t)



Woods – Resilience Engineering (cont.)



Resilience Engineering (cont.)



Resilience Engineering – 3 Basics



Failure Factors and Recovery



Patel, Cohen – Error in Critical Care



Time Course of Medical Error

Near Miss

Boundary

Normal Routine

Adverse Event ReportBoundary

Violation of consensual bounds of safe practice Error recovery: Detection and

correction of violation

Death

After Patel, 2007Component 15/Unit 10b

Health IT Workforce Curriculum Version 1.0/Fall 2010

11

Error Detection and Correction



Workflow Analysis and Modeling (Malhotra and Colleague: 2006)



Schematic Layout of the Cardio Thoracic Intensive Care Unit (CTICU) & Key Activities

(Malhotra et al 2007)

A, attending; R, resident; F, clinical fellow; PA, physicians assistant; N, nurse.Component 15/Unit 10b

Health IT Workforce Curriculum Version 1.0/Fall 2010

14

CTICU Critical Zones - Examples



Intensive Care Unit (ICU) and Critical Care



Factors in ICU Care



Care Goal Sheet (Pronovost)



Critical Care Environments



Virtual World Replay (from Vankipuram and Colleague: 2010)



Cognitive Taxonomy of Error (Zhang and Colleagues: 2004)



Errors



Cognitive Taxonomy of Error

Chain of events leading to error

From: Zhang and Colleague: 2004



Example of an Error and Questions It Raises (from Zhang, 2004)



Error Example (cont.)



Error Taxonomy



Taxonomy

From Zhang and Colleague: 2004



Examples From Zhang, 2004



Slip Stage in Action cycle

Examples

Execution slip

Goal slips Doctor was called out of the room to answer an urgent call and afterwards went to the room of a different patient who was next in the queue. (Loss of activation)

Intention slip A nurse intended to enter the rate of infusion using the up-down arrow keys, because this is the technique required on the pump she most frequently uses; however, on this pump the arrow keys move the selection region instead of changing the selected number (capture)

Action specification slips

A nurse intends to decrease a value using the decrement function, but pushes the down arrow key (which moves to the next field) instead of the minus key. (Associative activation)

Action execution slips

“I meant to turn off the antibiotics IV only, but turned off the infusion pump completely” (Double capture)



Examples From Zhang, 2004 (cont.)Slip Stage in

Action cycleExamples (From Zhang, 2004)

Execution slip

Goal slips Doctor was called out of the room to answer an urgent call and afterwards went to the room of a different patient who was next in the queue. (Loss of activation)

Intention slip

A nurse intended to enter the rate of infusion using the up-down arrow keys, because this is the technique required on the pump she most frequently uses; however, on this pump the arrow keys move the selection region instead of changing the selected number (capture)

Action specification slips

A nurse intends to decrease a value using the decrement function, but pushes the down arrow key (which moves to the next field) instead of the minus key. (Associative activation)

Action execution slips

“I meant to turn off the antibiotics iv only, but turned off the infusion pump completely” (Double capture)



Examples From Zhang, 2004 (cont.)Mistakes Stage in action

cycleExamples (From Zhang, 2004)

Execution mistakes

Goal mistakes Incorrect diagnosis due to neglect of base rate information (Biases)

Intention mistakes A physician treating a patient with oxygen set the flow control knob between 1 and 2 liters per minute, not realizing that the scale numbers represented discrete, rather than continuous settings (Incomplete knowledge)

Action specification mistakes

Strange burn scars appear in post-operative patients in a hospital. The problem was caused by electric discharge of a device that was not grounded. The device has a blinking red light to signal the problem, but the device operators did not know the meaning of the signal. (Incomplete knowledge)

Action specification mistakes

For example, a perfect knowledge of a surgical procedure may not lead to a successful surgical operation if the operator has not extensively practiced the procedure. (Dissociation between knowledge and rules)

Examples From Zhang, 2004 (cont.)



Evaluation Mistakes

Perception mistakes

A pharmacists filling prescription for Lamisil (an antifungal) mistakenly perceived Lamictal (an anticonvulsant) as Lamisil because he mistakenly expected it since he was looking for Lamisil. (Misperception)

Interpretation mistakes

A steady green light on an infusion pump means the device is ready, and a flashing green light indicates an infusion is in progress. The device user did not know the meaning of the steady green light, and correctly interpreted it as an indication that the infusion had begun. (Incorrect knowledge)

Action evaluation mistakes

In the infusion pump example the user may not know that the device has accepted the volume, and may then assume that the goal (‘set volume to be infused at 1000cc’) has not been accomplished, leading to a search for additional buttons (such as ‘enter’) to complete the goal (Incomplete knowledge)

Cognitive Interventions



Errors - Context



usability & human factors unit 10b designing for safety

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