Stuff that occurs to me

All of my 'how to' posts are tagged here. The most popular posts are about blocking and private accounts on Twitter, also the science communication jobs list. None of the science or medical information I might post to this blog should be taken as medical advice (I'm not medically trained).

Think of this blog as a sort of nursery for my half-baked ideas hence 'stuff that occurs to me'.

Contact: @JoBrodie Email: jo DOT brodie AT gmail DOT com

Science in London: The 2018/19 scientific society talks in London blog post

Thursday, 10 October 2013

What do you think about making errors, and strategies for avoiding them? Especially in medicine.

The CHI+MED project I'm working on has a side-project (called Errordiary) looking specifically at human error in medicine. This can be pretty devastating as when someone makes a mistake the consequences can be quite serious, including death, but more often just the sort of annoying harms that mean someone has a longer stay in hospital while something gets sorted.

There's often the assumption that doctors and nurses are highly trained and well-paid intelligent folk who shouldn't be making mistakes and should be paying attention - ie we hold medical personnel to much higher (unreasonably so) standards than ourselves, after all everyone makes mistakes. Another problem is that hospitals, wanting to be seen to 'do something' often contribute to this and blame the nurse or doctor, or possibly retrain them, or even sack them.

Unfortunately these responses rarely address the problem. Because humans can make a mistake at any time (no matter how well trained) training them more can't ever stop that. 

Researchers in human error would promote a more systems-view approach instead, one that takes account of the ways in which the devices being used (and the systems in which they're used) could be better designed to reduce the chance of error. Writing 'push' on a door doesn't guarantee that you won't pull it but it does reduce the chances a bit - and even writing it acknowledges that doors might open in two ways and that people might need a guide.

A great big decimal point on a medical device might make it a bit clearer that you're delivering 3.2 millilitres of drug per minute to a cancer patient rather than 32. A device that has presets that stop it working if more than 5 ml drug per minute is attempted would also help in that case. Different coloured insulin pens for fast and slow-acting insulins can reduce the chances the wrong one is used.

Errordiary project
The Errordiary project uses the Twitter hashtag #Errordiary to collect everyday examples of error - some are hilarious, some are annoying, some could be pretty serious. We've collected hundreds possibly thousands of these and they're used in teaching situations to reinforce the idea of the ever-present possibility of making an error. 

We also have another hashtag, #rsdiary, to collect examples of the strategies that people use to reduce their risk of making a mistake (remembering to write, and take with you, a shopping list increases the chances that you'll bring home what you wanted) - these are called resilience strategies.

The survey
We want to ask people what they think of and know about errors in everyday life, and also about their thoughts on resilience strategies. There are opportunities to win a small bit of money too (£10.00, not £1,000 - spot the decimal!). The survey's for general members of the public, healthcare professionals and also there's a category for people with diabetes. That's because people who have diabetes are often using one or more medical devices (blood glucose meter, insulin delivery device) and occasionally something will go wrong while in use. We know, from Twitter, that people with diabetes do have lots of resilience strategies - even if they might not use that academic term for them - and it's handy to (a) capture them and also more generally (b) get more people understanding that errors are everywhere and not a personal fault.

People with diabetes are already using other medical devices at home such as home haemodialysis units and the capacity for disaster following error is quite high there.

Here's the survey, it's a rather unlovely link I'm afraid but the content's very nice:

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