awalin sopan, catherine plaisant, seth powsner, ben shneiderman human-computer interaction lab &...
TRANSCRIPT
User Interface Techniques to Reduce Wrong Patient Errors
Awalin Sopan, Catherine Plaisant,Seth Powsner, Ben Shneiderman
Human-Computer Interaction Lab & Department of Computer Science,
University of Maryland
A Tale of Two Patients
http://www.nytimes.com/2002/06/18/health/oops-wrong-patient-journal-takes-on-medical-mistakes.html
A Tale of Two Patients
Mrs. Morris, 67 Mrs. Morrison, 77
They were in same hospital floor.
Mrs. Morris was taken to the operation room for the heart
surgery
Problems
• A drug administered to wrong patient
• Reading of wrong patients’ test results
• Patients miss needed treatment
• etc.
Is Computerized Patient Order System a Panacea for
These Problems?
interruption
fatigueurgenc
y
multitasking
long work-hours
Our ApproachError Classification
what are the error-scenarios clinicians face
Task Analysis which stage is more susceptible to a
particular type of error
27 Specific Techniques what to do, and then how to do it
Error Classification
Mistake
Slips
Failure to recogniz
e
Error Classification
Mistake
Slips
Failure to recogniz
e
Recalling the wrong patient due to short term memory failure, name similarity, unfamiliarity with the patient, fatigue.
Error Classification
Mistake
Slips
Failure to recogniz
e
Mechanical errors such as wrong key press, mouse slip, or errors due to unreadable fonts and too small button size.
Error Classification
Mistake
Slips
Failure to recogniz
e
Failures to detect errors due to interruptions, multitasking, absence of relevant information.
Task Analysis
Task Analysis
Task Analysis
Task Analysis
Task Analysis
UI Techniques:Reduce Mistakes Facilitate recall:▪ Provide more context: room number, photo,…
Avoid confusion:▪Emphasize the salient features: age, chief complaint,…
▪Use at least two sources of identification: name, medical record number,…
Facilitate Recall
Poor recall strategy, more mistakes
Other Techniques
Allow sorting Always show patient’s full name Scan RFID to retrieve the patient Use indoor location to retrieve the
patients
UI Techniques:Reduce Slips
Improve target-selection Improve text-readability Highlight target under cursor
Facilitate Selection
Poor selection mechanism, more slips
Highlight row under cursor Use an icon-based 2D grid instead of
list
Other Techniques
UI Techniques:Increase Recognition
Draw attention to patient information▪ Taieb-Maimon et al. : recognition increased from 7% to 43% with photo
Use decision support system
Increase RecognitionPoor verification, less error recognition
During Verification
Use visual summary of patient history
Avoid visual distraction Re-enter ID
Other Techniques
During Confirmation
What Guided Us
▪Human Error Classification▪Attention Theory▪Context Recovery Process▪Cognitive Task Analysis▪User Interface Design Principles▪Expert Feedback▪Medical Literature
Contributions
Categorization of the error-types, and sources
Suggestions of User Interface remedies
Prototype demonstrating the techniques
Take-away Messages
Small changes in the UI can make big difference in patient safety
Include Clinicians and HCI researchers in the design process
To err is human, the systems should make up for it
www.cs.umd.edu/hcil/WPE
www.youtube.com/watch?v=CrwOJIrnsg8
Awalin Sopan, Catherine Plaisant, Seth Powsner, Ben Shneiderman
We thank the Patient-Centered Cognitive Support under the Strategic Health IT Advanced Research Projects Program (SHARP) from the Office of the National Coordinator for Health Information Technology (Grant No. 10510592).