There's a focus group next Thursday in London for healthcare professionals to talk about the issues of error, blame and their resilience strategies to avoid errors. An example might be using a post-it note to flag up a reminder.
By their very nature people's 'resilience strategies' aren't official or found in manuals - we're collecting this sort of 'hidden' information to use in improving the design of medical devices.
Making devices more resilient to error can make them safer for patients.
Medical Professionals (e.g. nurses, doctors, paramedics and emergency care practitioners)
Thursday 26th September 2013
5.30-6.00pm – registration, food and refreshments
6.00-8.00pm – focus group
I work on the CHI+MED project which is about making interactive medical devices (such as cancer drug pumps and blood glucose meters for people with diabetes) safer and more resistant to error. One of the offshoots of the project is Errordiary* which collects examples of everday error and they're running a focus group next Thursday 26 September 2013 to find out about error, and its prevention, in healthcare.
In most situations we pretty much accept that everyone makes mistakes. If I turn up to the tube station and reach for my keys out instead of my rail card I've made a mistake. But no-one dies. There are no calls to retrain me and no-one's blaming me beyond some annoyed tuts from passengers behind me. The press is unlikely to scour my Facebook page for pictures of me drunk and incompetently trying to get through barriers with the wrong card, and I'm unlikely to lose my job.
We do tend to be a bit more blame-y towards people who work in healthcare when something goes wrong - these are highly trained individuals who are rarely 'permitted' to be human and make mistakes. When we ask for them to be sacked for incompetence we may be holding them to an impossible (unreasonably high) standard. When we ask for them to be retrained we may be wasting everyone's time if 'lack of training' had nothing to do with the fault in the first place.
No amount of training can really prevent me from grabbing the wrong thing but there are things that can be done to make it less likely.
Most people are right-handed so it's useful to have the control point on the right hand side (that's building resilience into the system) and it's sensible for me to keep my card in my right pocket. I can also keep my keys in my bag, so they're separate from my rail card!
On a chemotherapy pump it's easy enough to type in a wrong number: 52 instead of 5.2. Perhaps the visual display of the decimal point be clearer. Or the decimal point on the keypad could be in a better position. Perhaps the drug library installed on the pump could flag up that the drug dose is much higher than expected.
Hopefully the user will notice anyway and re-enter the correct figure - but what can be done to increase the chances that any error is spotted?
Finding out more about the errors that people make and how they avoid them, or recover from them, is a big part of tackling them and improving the safer use of devices.
Here's the blurb that I've pinched from my colleague Dom Furniss' post on the Errordiary focus group:
We are organising focus groups to find out more about what you think of human error, blame culture and resilience to error. We’re interested in mistakes – why we make them, how often we make them and what happens when we make them in trivial and serious contexts. For example:If you're a healthcare professional and free next Thursday please help, or tell a friend - thank you :)
- How often do you make errors? All the time, never or somewhere in between?
- What do you think about errors? Are they sometimes funny? What about when they happen at work?
- What do you think about fatal errors reported in the news? What do you think should happen to people after they’ve made a serious error?
- Should we share errors more? What are the pros and cons of this? What are the challenges?
- What can we do to prevent errors happening in the future?
"To err is human…Wiseman, S., Gould, S., Furniss, D., & Cox, A. (2012). Errordiary: Support for teaching human error. Paper presented at the Contextualised Curriculum Workshop at CHI 2012, Austin, Texas, May 2012.
To understand why we err and to try to reduce our erring is human too!
Errordiary is about sharing errors so people can think about human error in a new way. We already know that the same psychological principles lie behind everyday errors and those errors of a more serious nature. Whether they are funny, frustrating or fatal depends on the context."
From About Errordiary
You can see the latest tweets, tagged with #Errordiary (about errors) or #rsdiary (resilience strategies diary) too.
Further reading - preprints available to download as PDFs from the links given
Furniss, D., Back, J., & Blandford, A. (2012). Cognitive resilience: Can we use Twitter to make strategies more tangible? Proceedings of European Conference on Cognitive Ergonomics (ECCE 2012), 96–99. New York: ACM.
Lee, P. T., Thompson, F., & Thimbleby, H. (2012). Analysis of infusion pump error logs and their significance for health care. British Journal of Nursing (Intravenous Supplement), 21(8), S12-S20.
Furniss, D., Blandford, A., & Mayer, A. (2011). Unremarkable errors: Low-level disturbances in infusion pump use. Proceedings of the 25th BCS Conference on Human Computer Interaction (HCI-2011), 197–204.