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Applying Human Factors Engineering to Policies and …

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Incorporating Human
Factors Engineering into
Risk Reduction Strategies
Laura Lin Gosbee
Human Factors Engineer
Laura Lin Gosbee 10/30/03
My Background
• Human Factors
• University of Toronto – Institute of Biomedical Engineering/
Dept. of Mechanical & Industrial Engineering
• Northrop Grumman Corporation – Information
Technology Sector
• Applied R&D
• Systems Design & Evaluation
• Areas of Application
• Health Care - Toronto Hospital, Toronto, Canada
• Nuclear Power - Westinghouse, Pittsburgh, PA
• Military - Wright-Patterson Air Force Base, Dayton, OH
Laura Lin Gosbee 10/30/03
Overview
• Human Factors Approach
• What is it?
• What can it be applied to?
• How is it useful to your hospital?
• Applying Human Factors Engineering
• Proactive and Reactive Strategies
• Methods and Tools
• Human Factors case studies
Laura Lin Gosbee 10/30/03
Human Factors - What is it?
• Human Factors (HF) is the study of
human capabilities and limitations and the
application of that knowledge to the
design of systems
Laura Lin Gosbee 10/30/03
What can it be applied to?
Home Medical
Device
Spectrum of Complexity
Control Room
Defibrillator/Pacemaker
MRI safety
Electronic Patient Records
CPOE
ASO Policies
Crash Carts
Automated Dispensing Device
Laura Lin Gosbee 10/30/03
What can it be applied to?
 Equipment
Analyze
Design
Test
 Software
 Paper Forms
 Policies, Protocols, Procedures
 Workspace Layout
 Training & Education
What’s the commonality?
 All involve human-system interaction
Laura Lin Gosbee 10/30/03
How is it useful to your hospital?
 Add usability data to procurement
decisions
 Augment RCA and FMEA processes by:
• Relying less on guess work or brain-storming to
identify root causes or failure modes
• Expanding actions from RCAs beyond:
• be more careful, more training, more
policies, more rules to follow policies
Laura Lin Gosbee 10/30/03
QualityHealthcare.org
“Fundamental insights about human error
and the nature of accidents …shifts
attention away from the fault of
individuals to the larger contributing
factors, often hidden and almost always
out of their control.”
Laura Lin Gosbee 10/30/03
Example of Finding Root Causes
• Fighter planes before WWII
• Problem: planes crashing on night sorties,
explanation elusive
• “Simulate” by putting blanket over cockpit
• No lighting to see gauges, lack of other
visual cues
• Pilot error? No. HF design issue!
Laura Lin Gosbee 10/30/03
Key Messages
1.
Not all HF problems are as seemingly obvious
2.
Errors can be latent: “dormant” until night-time
sorties
3.
Example of human limitation: can’t see in the
dark
4.
Can’t always overcome with more training
5.
Policies, e.g., permitting only daytime sorties,
don’t tackle the problem
6.
Most effective solution is in design: add
cockpit lighting
Laura Lin Gosbee 10/30/03
Radar Scope to Detect Enemy
Ships
Laura Lin Gosbee 10/30/03
Performance Graph (curve)
Performance
100%
90%
80%
70%
1
2
3
4
Time (hours)
Laura Lin Gosbee 10/30/03
How can we move the curve upwards?
tactile feedback
auditory feedback
blinking
colour
shape
Performance
100%
90%
80%
70%
1
2
Time (hours)
3
4
Laura Lin Gosbee 10/30/03
Another Example:
• New house, new faucets
• Which way do you turn them?
A
B
C
D
Laura Lin Gosbee 10/30/03
Expectations and Biases
• Operation does not match expectations
• No visual cues on how to operate
• Negative transfer of training
• Inappropriate mental model: Lever faucets
B
Laura Lin Gosbee 10/30/03
In This Example
• Outcome not serious
• Finite number of ways to operate
• Danger of trial and error is not high
 Not always the case
In health care:
• systems not necessarily as forgiving
• not limited to a few ways of using it
• trial and error not safe or allowed
Laura Lin Gosbee 10/30/03
Example: PCA pump
•
Nurses program pump:
drug concentration, dose, 4 hour limit, etc.
•
Programming screen:
4 hour limit set? Yes or no?
•
Does it mean:
a) “have you already set it?”
b) “do you want to set it?”
•
At one hospital, for the first year, nurses
interpreted as a) and answered “no”
Laura Lin Gosbee 10/30/03
• Spend the next few minutes thinking of
an example that you experienced (or
saw happen to someone else)
• share it with the person next to you…
Laura Lin Gosbee 10/30/03
When is HF Applied?
• HF Methods can be applied to
PROACTIVE and REACTIVE risk
reduction strategies
Laura Lin Gosbee 10/30/03
Proactive Strategies
• When you want to keep “latent errors” from
creeping into your hospital, incorporate HF
when:
Purchasing new products
Designing and developing:
• in-house products or processes
• training & education programs
• workspace layout
Laura Lin Gosbee 10/30/03
Proactive Strategies
 Guide development of in-house products:
• policies/protocols, paper forms, software, devices, etc.
 Test/Validate before implementation
 Obtain usability data to compare products
before purchasing
 Conduct a prospective risk assessment
(FMEA) of systems
Laura Lin Gosbee 10/30/03
Targets for Proactive Strategies
 Equipment (syringes, automated dispensing
devices)
 Connections for IV tubing, Oxygen
 Drug labels and storage
 Policies, procedures and protocols (new and old)
 Software (CPOE, patient records)
 Paper forms (order forms, checklists, warning
signs, policy manuals)
Laura Lin Gosbee 10/30/03
Reactive Strategies
• When you have to solve existing
problems, incorporate HF when:
Investigating adverse events
Laura Lin Gosbee 10/30/03
Reactive Strategies
 Use HF to help identify vulnerabilities
or contributing factors in an RCA
 Use HF methods when developing and
validating RCA actions
Laura Lin Gosbee 10/30/03
Targets for Reactive Strategies
 Equipment (syringes, automated dispensing
devices)
 Connections for IV tubing, Oxygen
 Drug labels and storage
 Policies, procedures and protocols (new and old)
 Software (CPOE, patient records)
 Paper forms (order forms, checklists, warning
signs, policy manuals)
Laura Lin Gosbee 10/30/03
Sampling of HF
Methods and Tools
HF Testing
HF Analysis
•Human-in-the-loop
•User-centered testing
•Usability Testing
•Cognitive Walkthrough
•Heuristic Evaluation
•Simulator Testing
(part-task, full-scale)
•Task Analysis
•Field Observations
•Interviews
•Bench Tests
•Cognitive Walkthrough
•Heuristic Evaluation
HF Design
•HF Design Principles
•Results from Analysis phase
•Standards & Guidelines
Laura Lin Gosbee 10/30/03
What can it be applied to?
 Equipment
Analyze
Design
Test
 Software
 Paper Forms
 Policies, Protocols, Procedures
 Workspace Layout
 Training & Education
Laura Lin Gosbee 10/30/03
HF Analysis
Tasks
Subtasks
GUI Screens
of each Subtask
Task 1
Decision/Action Diagrams
for each GUI Screen
screen 1
D1
Subtask 1
Task 2
Subtask 2
screen
2
D2
screen 3
screen 4
screen 5
screen 6
screen 7
screen 8
screen
9
D3
D4
D5
A1
A2
A3
A4
D7
D8
D9
D1
0
D6
A5
A6
Subtask 3
Task 3
screen 10
Task 4
(TASK
FLOW)
screen 11
A7
A8
A9
A13
screen 12
Abstract Level
Detailed Level
D1
1
A10
A11
A12
A14
(INFO
FLOW)
Laura Lin Gosbee 10/30/03
HF Analysis
Tasks
Subtasks
GUI Screens
of each Subtask
Task 1
Decision/Action Diagrams
for each GUI Screen
screen 1
D1
Subtask 1
Task 2
Subtask 2
screen
2
D2
screen 3
screen 4
screen 5
screen 6
screen 7
screen 8
screen
9
D3
D4
D5
A1
A2
A3
A4
D7
D8
D9
D1
0
D6
A5
A6
Subtask 3
Task 3
screen 10
Task 4
screen 11
screen 12
A7
A8
A9
A13
D1
1
A10
A11
A12
A14
Correct Decision/Action
Path
Deviations from correct
Decision/Action Path
Laura Lin Gosbee 10/30/03
HF Design
Old Task Structure
Redesigned Task Structure
Laura Lin Gosbee 10/30/03
HF Testing
• What can be tested?
 Devices
 Software
 Forms
 Processes
 Policies
 Procedures, etc.
Products from policy/protocols:
•Instruction material
•Cognitive aids (cheat sheets)
•User manuals
•Memos
•Alerts or Warning Signs
• Testing works just as well for written
material as it does for devices!
Laura Lin Gosbee 10/30/03
HF Testing
• Example - Protocol to be Tested:
Protocol for Preparing
Medication
Step 1 Step 2 Step 3 Step 4 –
Etc.
Useful?
Usable?
Learnable?
Accepted?




Readability
Content
Layout
Usability of
associated material:
drug labels, vials,
tubing, connections,
IV pumps, cartridges
storage & retrieval
Laura Lin Gosbee 10/30/03
HF Methods & Tools
A few of many…
1. Cognitive Walkthrough
2. Heuristic Evaluation
3. Usability Testing
Laura Lin Gosbee 10/30/03
1. Cognitive Walkthrough
Preparation:
• Recruit end “users”
• Develop “scenarios” & “tasks”
Methodology
• Participants think aloud as they “walk” you through
using a system/protocol
• Use a variety of scenarios
• Ask them to verbalize any decision or mental step
• Record difficulties
Laura Lin Gosbee 10/30/03
2. Heuristic Evaluation
Preparation
• HF design principles
• Design guidelines/standards (AAMI/ANSI)
• Guidelines for medical applications, e.g., Do it by
Design, Write it Right (FDA)
Methodology
• Essentially a usability audit
• Evaluate against guidelines & design principles
• Evaluate both form (e.g., visual design) and
content
Laura Lin Gosbee 10/30/03
Human Factors Engineering Guidelines
1)
2)
3)
4)
5)
6)
7)
8)
Overall Human Factors
Feedback and Visibility of System Status
Consistent Model or Metaphor
Functionality of Controls
Displayed Messages
Recognition and Recovery from Errors
Minimizing User Memory Load
Readable and understandable labels and warnings
Laura Lin Gosbee 10/30/03
Triggering Questions*
* Human Factors Tool developed by: John Gosbee & Laura Lin Gosbee
Feedback and Visibility of System Status
• When you try to do things, how do you know you are
successful? ·
• Do you know what the device is doing at any given
moment?
• If you are distracted, can you tell immediately where
you've left off?
• If you handed the device to someone, does it take
them long to figure out where you've left off and what
the device is doing?
Laura Lin Gosbee 10/30/03
Triggering Questions*
* Human Factors Tool developed by: John Gosbee & Laura Lin Gosbee
Functionality of Controls
•
•
•
•
•
•
Is it obvious what each button or switch will do?
Do they work the same in different circumstances?
Do some buttons/switches look too similar to others?
Are they grouped/located in a logical manner?
Are some controls more critical than others?
If so, how are they differentiated from other controls?
Laura Lin Gosbee 10/30/03
Triggering Questions*
* Human Factors Tool developed by: John Gosbee & Laura Lin Gosbee
Displayed Messages
•
•
•
•
•
•
Is the message display big enough?
Can you understand the messages?
Is the language simple and natural?
Is the information useful?
Do you need more information?
Is it displayed long enough for it to be useful?
Laura Lin Gosbee 10/30/03
3. Usability Testing
Preparation
• Recruit end users
• Develop “scenarios” and “tasks”
• Select test site
• Performance measures (e.g., errors, time to
recover from errors, mental workload)
• Test plan (experimental design & protocol)
Methodology
• Generally, participants are asked to carry out a ‘task’
while performance data is collected unobtrusively
Laura Lin Gosbee 10/30/03
Performance Goals
Performance Benchmarks
Examples:
• 90% people using it “cold” can do it without
errors
• 80% people interpreting the policy can
understand the rationale or implications
Laura Lin Gosbee 10/30/03
Example:
Epinephrine Auto-Injector
• Epinephrine used for Anaphylaxis
• Auto-injector administers epinephrine
• Device is used in emergency situations
Laura Lin Gosbee 10/30/03
A Quick and Dirty Usability Test
• Design Goal (performance goal): lay
person can use it in an emergency with no
prior training
• Volunteer with no previous
experience with auto-injectors
• Using a “trainer” – NO NEEDLES!
Laura Lin Gosbee 10/30/03
Scenario
• I just ate some cookies with traces of
peanuts
• I am going into anaphylactic shock… I’ve
stopped breathing
• You are alone with me and found my autoinjector
• Need to administer it quickly before the
unthinkable…
Laura Lin Gosbee 10/30/03
Lessons
• Design helps/hinders human
performance
• Environment of use specifies
performance requirements
(benchmarks)
• lay person, little or no training, timeliness
*Gosbee LL.
Nuts! I can’t figure out how to use my life-saving auto-injector: Human factors
issues associated with an epinephrine auto-injector. Joint Commission Journal on Quality and
Safety (in press).
Laura Lin Gosbee 10/30/03
Case Study: HF analysis of
“confusion”
• Hospital in Salt Lake City had many issues with code
teams
• One issue they observed many times was confusion
and delay with medication drawer retrieval
• They performed usability (HFE) testing with
• 9-11 end-users
• Retrieving 10 medications
• Five versions of the drawer
*McLaughlin RC. Redesigning the crash cart: usability testing improves one
facility's medication drawers. Am J Nurs. 2003;103(4):64A,64D,64G64H.
Laura Lin Gosbee 10/30/03
Baseline Drawer
(“Laundry hamper”)
Range = 2:43-3:58 min, Avg=3:07 min
Laura Lin Gosbee 10/30/03
Code Cart Drawer Fifth Version
Range = :55-1:25 min, Avg=1:08
Note the
lack of
labels for
each spot
Laura Lin Gosbee 10/30/03
Case Study: PCA pump
• University of Toronto and Toronto
General Hospital
• 1993: nurse complaints about “new
device”: PCA pumps
• HF study:
• HF analysis
• redesign
• user testing
Laura Lin Gosbee 10/30/03
PCA: Interface Redesign
Existing Design
New Design
Laura Lin Gosbee 10/30/03
PCA: Programming Sequence
Redesign
Existing Design
New Design
Legend
Decision
Message-guided
Action
Action
Laura Lin Gosbee 10/30/03
User population
Tested with 2 user populations:
 Novice users
• Nursing students n=12
 Expert users
• Recovery Room Nurses n=12
Laura Lin Gosbee 10/30/03
Results
Advantages seen with new design:
Dependent
Variable
Errors
Task
Completion
Time
Mental
Workload
User Preference
Nursing
Students
Recovery Room
Nurses
50% fewer *
55% fewer *
15% faster *
18% faster *
53% lower
14% lower
100% *
90% *
* Denotes statistically significant
Laura Lin Gosbee 10/30/03
Implications
• Redesigning this PCA pump reduced time and
errors  $$
• Redesigning the device is in the hands of the
device maker, but…
• Provide your input to device makers (proactive)
• Ask for HF/usability test data from them (proactive)
• Consider HF in procurement decisions (proactive)
• Provide HF training for front-line personnel (proactive)
• Consider HF in RCAs (reactive)
Laura Lin Gosbee 10/30/03
What else can you do?
• Could other interventions reduce errors,
time etc.?
• Maybe. BUT limited effectiveness - just
compensating for a poorly designed
device
• What kind of interventions?
Laura Lin Gosbee 10/30/03
Other Interventions
Other less effective interventions within your
control
• Provide cognitive aids e.g., Redesign pca order form:
use HFE analysis to design and validate
• Workplace redesign
e.g., program pumps in an area with
fewer distractions; may impact other processes (e.g., cause disruptions in
workflow); use HF to design & validate
• Training
use HF analysis to develop training materials; understand
that no amount of training can completely overcome a poorly designed
device; don’t schedule training 6 months before devices arrive without followup training
• Policies
e.g., double check by 2nd person; less reliable, adds time,
effort
Laura Lin Gosbee 10/30/03
Example of a Cognitive Aid
PCA Order Form
Concentration Units
Concentration
Bolus Dose
Mode
PCA Dose
Lockout
Continuous Rate
4 Hr Limit
•
Test to validate
•
Design depends on configuration of
the specific device
Laura Lin Gosbee 10/30/03
Leveraging Factors
Device Design
Policies
PCA Order
Form
User
Training
Work
Environment
Laura Lin Gosbee 10/30/03
Policies to Fix Design Issues:
Unintended Consequences
• Does it solve problems without introducing
other unintended problems?
• Example: County Jail Policies
Laura Lin Gosbee 10/30/03
 Policy #1: All officers shall remain
with their prisoner while booking
(paperwork) is completed
Laura Lin Gosbee 10/30/03
 Policy #1: All officers shall remain
with their prisoner while booking
(paperwork) is completed
 Forcing Function to reinforce
Policy # 1: Desk was removed,
forcing officers to use small
counter space near prisoner
Laura Lin Gosbee 10/30/03
 Unintended Result: Prisoner belongings get
obscured by clutter. Policy # 2 gets violated.
Laura Lin Gosbee 10/30/03
 Unintended Result: Prisoner belongings get
obscured by clutter. Policy # 2 gets violated.
 Policy # 2: All prisoner belongings shall be
admitted into evidence or the property room
before prisoner is booked.
Laura Lin Gosbee 10/30/03
 Policy # 3: “Failure to follow these rules
will result in more rules”
Laura Lin Gosbee 10/30/03
Think about HF design
interventions
• Redesign countertop space to
accommodate process
• Redesign the software so that clerk can
register belongings at any time
• Redesign forms: make it obvious that they
must enter prisoner belongings before
anything else
Laura Lin Gosbee 10/30/03
Last Example:
Auto-Injector revisited
• Epinephrine auto-injector for
anaphylaxis
• Patients are advised:
 Carry it at all times
 May want to carry 2 in case:
• one fails or
• need another dose
Laura Lin Gosbee 10/30/03
Case Study
• 3 yr old with history of severe nut
allergies
• History of contact-induced reactions
• Compliance is a dismal 40% !!
Laura Lin Gosbee 10/30/03
Solutions?
 More education?
 Create policy?
 Reminders?
 Reprimand?
 HF design intervention?
Laura Lin Gosbee 10/30/03
HF Design Problem and
Intervention
Design Problem:
• Bulky, won’t fit in pockets
• Can’t withstand temperature extremes
• Can’t be exposed to sunlight
HF Intervention:
• Protective carrying case that clips to belt
• Hang it by the door
• Attach it to keys
Laura Lin Gosbee 10/30/03
Effectiveness of Solution
 Compliance went from 40% to 98%
• 2 percent non-compliance attributed to
factors known as:
“Terrible-Twos” and “Fearsome Fours”
•
•
•
•
Sleep deprivation
Time pressure
Interruptions
Occupational Stress
Laura Lin Gosbee 10/30/03
References
Gosbee JW, Lin L. The role of human factors engineering in
medical device and medical system errors. In C. Vincent (ed.)
Clinical Risk Management: Enhancing Patient Safety. London:
BMJ Press. 2001.
Lin L, Isla R, Doniz K, Harkness H, Vicente K, Doyle DJ. Applying
human factors engineering to the design of medical equipment:
Patient-controlled analgesia. J. Clin. Monit. 1998; 14: 253-263
Lin L, Vicente K, Doyle DJ. Patient Safety, potential adverse drug
events, and medical device design: A human factors engineering
approach. J. Biomed. Informatics. 2002.
Schneider PJ, Gosbee JW, Lathan C, Shapiro RG, Marx D. The
application of human factors engineering to improve medication
use safety. American Society of Health-System Pharmacy
Journal. 2002.
Laura Lin Gosbee 10/30/03
References
Rubin J. Handbook of Usability Testing: How to Plan, Design, and
Conduct Effective Tests. New York: John Wiley & Sons. 1994
Roth, E. M. & O'Hara, J. Exploring the impact of advanced alarms,
displays, and computerized procedures on teams. In Proc. of the
Human Factors and Ergonomics Society Annual Meeting Santa
Monica, CA: Human Factors and Ergonomics Society. P.158-162.
1999.
Guerlain S, LeBeau K, et.al. Effect of a standardized data collection
form on the examination and diagnosis of patients with abdominal
pain. In Proc. of Human Factors and Ergonomics Society Annual
Meeting. Santa Monica, CA: Human Factors and Ergonomics
Society. 2001.
Wieringa DR, Farkas DK. Procedure writing across domains:
Nuclear power plant procedures and computer documentation.
Proceedings of the Association for Computing Machinery. New
York: ACM Press. P. 49-58. 1991.
Laura Lin Gosbee 10/30/03
Questions? Comments?
Laura Lin Gosbee
Human Factors Engineer
LLGosbee@covad.net
Laura Lin Gosbee 10/30/03
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