usability & human factors unit 10b designing for safety
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Usability & Human Factors
Unit 10bDesigning for Safety
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Woods and Colleague: Resilience Engineering
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Woods and Colleague:Challenger Analysis
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‘Failure of Foresight’
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Woods and Colleague:Challenger Analysis (con’t)
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Woods – Resilience Engineering (cont.)
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Resilience Engineering (cont.)
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Resilience Engineering – 3 Basics
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Failure Factors and Recovery
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Patel, Cohen – Error in Critical Care
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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
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Error Detection and Correction
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Workflow Analysis and Modeling (Malhotra and Colleague: 2006)
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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
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CTICU Critical Zones - Examples
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Intensive Care Unit (ICU) and Critical Care
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Factors in ICU Care
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Care Goal Sheet (Pronovost)
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Critical Care Environments
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Virtual World Replay (from Vankipuram and Colleague: 2010)
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Cognitive Taxonomy of Error (Zhang and Colleagues: 2004)
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Errors
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Cognitive Taxonomy of Error
Chain of events leading to error
From: Zhang and Colleague: 2004
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Example of an Error and Questions It Raises (from Zhang, 2004)
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Error Example (cont.)
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Error Taxonomy
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Taxonomy
From Zhang and Colleague: 2004
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Examples From Zhang, 2004
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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)
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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)
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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)
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Examples From Zhang, 2004 (cont.)
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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)
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Cognitive Interventions
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Errors - Context
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