Human Factors Engineering

Human Factors Engineering (HFE) and Patient Safety : Human Factors Engineering (HFE) and Patient Safety With thanks to John Gosbee


What’s HFE? : What’s HFE? Designing things or processes to fit human abilities and limitations Designing the glove to fit the hand, not the hand to fit the glove (supporting/improving human performance by as little as 3-10% will make things much safer) Using specific ways to uncover hidden needs, assumptions and unexpected interactions (“heuristic evaluation”, “usability testing”) Taking advantage of knowledge about human capabilities (5 senses, communication styles, ranges in physical size and strength, etc.)


Human Factors Model : Human Factors Model Senses - Vision - Hearing Psychomotor - Hand - Eye movements Input Devices Keyboard - Voice recognition Output - CRT - Sound INTERFACE


HFE and Healthcare : HFE and Healthcare Academia University of Wisconsin (BME-IE) Catholic University in DC (BME) Government FDA-CDRH (great web site) NIH-NCI usability for patient information (www.usability.gov) Industry Medtronic (over 8 years) Baxter and Abbott (more recently)


How good are we at vigilance/paying attention? : How good are we at vigilance/ paying attention?


Performance Graph : 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance Performance Graph


Performance Graph : 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance Performance Graph


How can we move the curve up (improve performance)? : How can we move the curve up (improve performance)? 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance


How fast can we learn things? : How fast can we learn things? When I say “up”, everyone raise your hand as quickly as you can


This was not an aerobic exercise : This was not an aerobic exercise Demonstrates: “paired associate learning” Case Study Frequently used pharmacy computer used “ENTER” button for data entry Pharmacy computer used 10% of time “SPACE BAR” for data entry


What assumptions do we make? : What assumptions do we make? For example: Do we make important decisions based on equipment color?


What is the content of these gas cylinders? : What is the content of these gas cylinders? Write your answer down on paper.


What is the content of this  gas cylinder? : What is the content of this gas cylinder? Write your answer down on paper


What is the content of these  gas cylinders? : What is the content of these gas cylinders? Write your answer down on paper


What is this regulator used for? : What is this regulator used for? Write your answer down on paper


What is this regulator used for? : What is this regulator used for? Write your answer down on paper


Demonstration: Stroop Test : Demonstration: Stroop Test Row 1 Row 2 Row 3


Now, State the Color of the Text as Fast as You Can… : Now, State the Color of the Text as Fast as You Can… Red Red Red Blue Blue Blue Yellow Yellow Yellow Green Green Green Row 1 Row 2 Row 3


Again, State the Color of the Text as Fast as You Can… : Again, State the Color of the Text as Fast as You Can… Red Red Red Blue Blue Blue Yellow Yellow Yellow Green Green Green Row 1 Row 2 Row 3


Oxygen? : Oxygen?


Answer? : Answer?


Is this 95% CO2 OR 95% O2? : Is this 95% CO2 OR 95% O2?


Slide23 : A – CO2 B – O2 C – O2 A B C


Oxygen : Oxygen


Air : Air


“Quotes” from Adverse Events : “Quotes” from Adverse Events “Quickly, have the transport person to [SIC] get the green tank and hook it up to the patient!”


Let’s see, the green tank is … : Let’s see, the green tank is …


“Quotes” from Adverse Events : “Quotes” from Adverse Events “Tell the nursing student to attach the oxygen mask and tubing to the green spigot” Remember, this is air.


“Quotes” from Adverse Events : “Quotes” from Adverse Events “Get the green and gray tank and put it in the endoscopy cabinet & attach it to the insufflator valve” Green tank and Gray tank? Green and Gray tank….?


Can we ignore equipment color? : Can we ignore equipment color? “Ignore the color in some cases, focus on the label…” Summary from an ECRI Alert “Color is not fool-proof, only read and trust the label” Guideline from the Compressed Gas Association


HFE and Actions that make things safer : HFE and Actions that make things safer Warning: Lost Fingers


Some HFE Actions : Some HFE Actions Warnings and labels Training Policies and Procedures Checklists Simplify, standardize Interlock, lock-out, forcing functions Specialized communication (e.g., read back) Physical plant changes


What’s the best action? : What’s the best action? Chose physical over procedural actions (example) Chose permanent over temporary actions (example) Put “knowledge in the world”… reduce the burden on human memory and vigilance (Donald Norman)


Small Group Exercise : Small Group Exercise Groups of 3-5 people One person as Director Job is to remind end user to think out loud; leads team after evaluation One person as End User Job is to USE the product Other members as Observers Note words used, facial expressions, etc. Purpose of Exercise - Find problems and recommend HFE redesign of the product


Some Common Design Problems : Some Common Design Problems Inconsistent labels, buttons, knobs, etc. Unreadable and confusing/ambiguous labels No obvious mental model for how the thing works Unclear automation What is it doing? Why is it doing that? “Mode” errors Not considering environment of use


Remember … : Remember … It’s all about supporting perfect human performance (for you, for me, for the next person … first time and every time) “It’s not me, it’s bad design” “It’s a marathon, not a sprint”