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Patient Safety and Human Factors Engineering Anne Arundel Community College Arnold, MD Carolyn Jenkins MSN, RN Spring, 2006 Adapted from John Gosbee, MD, MS VA National Center for Patient Safety [email_address]   www.patientsafety.gov
[object Object],[object Object],[object Object],[object Object],OBJECTIVES
Kyle, L. (2005). First place winner. The faces of caring: Nurses at work. 105,6.
[object Object],[object Object],[object Object],[object Object],[object Object],What is Human Factors Engineering?
Broad Impact of Human Factors Engineering ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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.  http://www.hf.faa.gov/webtraining/index.htm FEDERAL AVIATION ADMINISTRATION Improved system design results in reduced costs and improved productivity/performance.                                                                                                                               
http://www.baddesigns.com/ Bad Design Kills
Human Factors Model Senses - Vision  - Hearing ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Output - CRT  - Sound INTERFACE
Radar Scope to Detect “enemy” ships
Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
How can we move the curve upwards?   100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
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 Blue Yellow 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 Blue Yellow 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 Example Patient 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 Human Factors to the Design of Medical Equipment: Patient-controlled Analgesia.  Journal of Clinical Monitoring and Computing  14: 253-263.
PCA: Programming Sequence  Redesign Existing Design New Design Decision Message-guided Action Action Legend
User population ,[object Object],[object Object],[object Object],[object Object],[object Object]
Usability Evaluation of a PCA Pump:  Measurements ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PCA Pump Errors - Results ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other Results ,[object Object],[object Object],[object Object],[object Object],[object Object]
Healthcare “Systems ” Range from the Simple to Complex ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
"Don't worry--it always beeps when you do that!"
Multi-Channel Infusion Pump
 
Human Factors Engineering is about the whole system ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Human Factors Engineering and Your World ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Take home points: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
HFE Exercise:  Groups of 3-4 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Human Factors Engineering ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Web sites for Patient Safety
References: ,[object Object],[object Object],[object Object],[object Object],[object Object]

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Human Factors Engineering Improves Patient Safety

  • 1. Patient Safety and Human Factors Engineering Anne Arundel Community College Arnold, MD Carolyn Jenkins MSN, RN Spring, 2006 Adapted from John Gosbee, MD, MS VA National Center for Patient Safety [email_address] www.patientsafety.gov
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  • 3. Kyle, L. (2005). First place winner. The faces of caring: Nurses at work. 105,6.
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  • 6. 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. http://www.hf.faa.gov/webtraining/index.htm FEDERAL AVIATION ADMINISTRATION Improved system design results in reduced costs and improved productivity/performance.                                                                                                                               
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  • 9. Radar Scope to Detect “enemy” ships
  • 10. Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
  • 11. Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
  • 12. How can we move the curve upwards? 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
  • 13. Demonstration: Stroop Effect Row 1 Row 2 Row 3
  • 14. Now, State the Color of the Text as Fast as You Can… Red Red Red Blue Blue Blue Yellow Yellow Yellow Green Green Green Row 1 Row 2 Row 3
  • 15. Again, State the Color of the Text as Fast as You Can… Red Red Red Blue Blue Blue Yellow Yellow Yellow Green Green Green Row 1 Row 2 Row 3
  • 16. Count the number of times the word “ RED ” appears in this example .
  • 17. “ 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
  • 18. Knee-jerk vs. HFE-based Remedy Make “sure” to use the correct color Adaptor!? Better
  • 19.  
  • 20. HFE Example Patient 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 Human Factors to the Design of Medical Equipment: Patient-controlled Analgesia. Journal of Clinical Monitoring and Computing 14: 253-263.
  • 21. PCA: Programming Sequence Redesign Existing Design New Design Decision Message-guided Action Action Legend
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  • 27. "Don't worry--it always beeps when you do that!"
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Notes de l'éditeur

  1. Start lecture by asking for information about tools and equipment used in the health care setting 50 years ago and currently??? Place this info on the board.