Forced Errors: Can We Design Away Mistakes For A Safer Healthcare System?
News A nurse misreads a medication label, mis-programs an infusion pump, or simply doesn't notice that they are using the wrong syringe. These mistakes can cause injury and death, and many would say that they are egregious. Yet they happen every day.
While the patient safety movement of the last ten years has made progress in removing the blame from individuals and focusing on systemic contributions to error, one thing has remained the same: Healthcare is an industry that continues to rely heavily on people, and people make mistakes.
What's worse though, is that the design of that label, that pump, and that syringe likely compounded the inherent human fallibility that caused these errors.
"More and more frequently though, caregivers and patients alike are demanding that healthcare products be as easy to use as the consumer technology they use every day. "
The discipline of Human Factors allows us to understand human fallibility and design systems that are optimized to make allowances for our weaknesses and capitalize on our strengths. It involves working closely with caregivers and patients, psychologists, designers and engineers to understand the use environment, how people work, how common mistakes happen and then iterating together to design solutions that are resilient to human error.
It's possible to create a label that has critical information prominently displayed that is more easily legible, a pump that prevents overdosing or under-dosing if a finger slips while programming it, and a syringe that contains a potentially fatal blood thinner to be more distinguishable than the others.
While it applies to all aspects of healthcare; processes, environments, protocols and medication labels, Human Factors is becoming increasingly relevant with respect to the design of healthcare technologies. These are becoming so sophisticated that even the highly qualified personnel charged with operating them can, at times, be at loss to fully understand them.
Unlike consumer technologies that have short 1-2 year life cycles and are designed to enhance the user’s experience, healthcare technologies have implementation cycles on the order of a decade, and are often bloated with extraneous features and unnecessarily complex. The implication is that healthcare systems are often stuck with technologies that are unsafe for their patients.
The good news is that this rigorous Human Factors approach to designing healthcare is gaining traction. Regulators like the US Food & Drug Association now require evidence of Human Factors based testing and risk mitigation strategies for medical devices, before they’ll approve them for use.
"More and more frequently though, caregivers and patients alike are demanding that healthcare products be as easy to use as the consumer technology they use every day."
More and more frequently though, caregivers and patients alike are demanding that healthcare products be as easy to use as the consumer technology they use every day. Unlike the piecemeal approach to designing healthcare of our past, these developments are creating a clear and comprehensive vision towards a future system that is firstly safe.