AMIA Webinar: Using Distributed Cognition for Investigating Medical Device Design and Use in Context
This picture shows a lovely contrast between an error in an everyday situation and a safety critical situation. Both the error and the potential error have similar underlying psychological causes but the consequences of their outcomes are very different.
Errordiary is a website and Twitter stream that helps reveal these sorts of interesting contrasts. Errordiary collects errors from the public, which can be funny, frustrating and fatal from different contexts. Visit Errordiary to learn more about how we are using these ideas for teaching, research and public engagement, and how to get involved.
Formula One has undergone a safety revolution over the past 30 years, is there similar movement happening in healthcare?
Just a few weeks ago I was following updates from the Patient Safety Congress 2014 on Twitter when I was irritated by a remark reportedly made by Jeremy Hunt. It sounded like he was making a ridiculous comparison, and I’ve heard others express concerns about over stretching comparisons with the airline industry too. There is some value in it by flying a plane is very different to running the NHS. Carl defended the vision and more importantly helped me see that we should be positive about radical change. In part, this is what triggered this blog post:
Carl’s link pointed to the 1955 Les Mans disaster in which 83 spectators and a driver died, and a further 120 were injured when large bits of debris flew into the crowd. Motorsport has come on leaps and bounds: we never see these sorts of disasters and rarely see fatal accidents in the modern sport. Perhaps there is more to this analogy, and perhaps it could be a better comparison than the airline industry too. [Thanks Carl for getting me thinking and helping to spark this post.]
Around the time of this Twitter exchange I had a LoveFilm DVD waiting for me at home, Life on the Limit, which serendipitously turned out to be a documentary about the safety revolution in Formula One. I think I ordered it after being very impressed by TT: Closer to the Edge, Senna, and Rush – all great! I’m not a petrol head, but I am interested in good documentaries and human-machine interaction. On the documentary side I am a bit of an amateur filmmaker, so watching great docs like these is a bit like going to a flash restaurant and appreciating the way the meal has been created, whilst going back home to oven cooking and beans on toast. On the man-machine interaction side I’m a human factors postdoc who looks at the design and usability of medical devices for my research. Both of these come together in Man-Machine Nightmares, which is a film I made about my research few years ago.
Life on the Limit is a great documentary. It tells the story of how Formula One has evolved from a very dangerous sport in the 1960’s to being the much safer sport it is today. It is a story of personalities, advancing technology, competing pressures, tragedy and drive (pardon the pun): this drive is to go faster, to win, and to preserve life.
The result of this journey can be revealed by juxtaposing the first crash the film covers in 1967 where Lorenzo Bandini died in a fiery crash and Martin Brundle’s huge crash in Melbourne in 1996. The first was a tragedy, but it was accepted as part of the risk of this dangerous game.
The second was a triumph for safety (you can watch the first minute or so of the YouTube clip below). After the crash Martin runs down the track to rejoin the race in his spare car! The race was stopped, there are safety barriers, there are plenty of trained stewards, and this crash happened shortly after big changes to improve the safety of the cars. This included raising the shoulders of the driver’s cockpit so if the car flipped that protected the driver’s head.
Over the course of those 30 years there were many deaths, lessons were learnt, and perhaps most importantly there was a culture change – it was no longer acceptable for people to die in the name of sport.
There are a number of messages and comparisons that I’d like to highlight from the film, which I think are pertinent to the human factors and safety movement in healthcare too:
- Motorsport is often focused on the driver, but the safety story is really focused on the system, e.g. the design of the car, helmet, safety barriers, safety car, trained stewards, fire equipment and procedures, protection for spectators, etc. In healthcare we should also focus less on the individual and more on the system, e.g. intuitive medical devices, checklists and procedures, staffing levels, good training, etc.
- For deep-rooted cultural change you need a change in attitude by people who run the business. Racing car drivers will race to the limit – it is up to management to manage and set those limits, so performance is within safe boundaries for everyone. MPs saying safety first is too simplistic when they won’t resource these changes.
- Focusing on why someone crashed or why an error was made is wrong. Instead we should ask why the driver died or why the patient was harmed. Mistakes will always happen and the system needs to compensate for that. Max Mosley pushed for a car that would protect the driver in any circumstances and this is why Martin Brundle rejoined the race rather than becoming the next tragedy. We need a healthcare system that is tolerant to mistakes.
- Similar to motorsport, healthcare has benefited from great technological advances that expand the boundaries of performance. This also adds pressure and complexity to users, e.g. racing drivers take corners at higher speeds, and ICU nurses handle 10+ infusion pumps instead of just one. Safety needs to keep up.
- Public pressure comes from exposing accidents and high profile cases. When tragedies were hidden there wasn’t the pressure for change. It took high profile cases to turn the tide, e.g. by Senna dying. For the first time people wanted to know why this man died and why racing was so dangerous. What are or what will be healthcare’s high profile cases?
- Leaders have a key role to play, e.g. Niki Lauda gave away his championship because he decided that a race was just too dangerous to drive in. This was unheard of. It put safety on the agenda at the highest level. Leaders don’t just go with the flow, they push for the right decision even when this is against the grain.
- We shouldn’t accept the status quo. Many thought the dangers were just part of the game, drivers were expected to put their lives on the line, and not everyone was expected to make it through the season. A few people did not accept this and led the safety movement. They were positive about radical change.
- Being more careful or trying harder aren’t sufficient to bring real advances in safety, it takes something else. Science, investigation, testing, reflection, and improvement have a key role to play. Cars were put through crash tests, and a safety director was appointed who brought wide and far reaching changes to the safety of every race. We need to incorporate the right expertise to achieve this change.
- Lessons learnt from those that have died are not cheap – they should be investigated and improvements made. As Captain Sully, who famously landed his aircraft on the Hudson said, “Everything that we know in aviation, every procedure that we have, every rule in the book, every technique that we have, ultimately is because someone somewhere died… What we have learned are lessons purchased at great cost – many of them literally bought with blood.” Cited in http://www.huffingtonpost.com/brian-goldman-md/doctors-make-mistakes-can_b_1968268.html
- “It’ll never happen to me…” is something that the drivers thought. In a similar way surgeons, doctors, nurses, hospital porters, administrators and directors should not think that it’ll never happen to them, and Trusts should not think that it’ll never happen there. Being mindful means accepting that things could happen. I once asked someone who used to be involved in controlling a nuclear power plant about potential errors, and he said anything could go wrong. I was stunned. I expected him to say nothing could go wrong, and I wondered why someone in charge had this attitude! It took a while, but I realised having this attitude was right for the position, and was one of the reasons why he was in charge.
Going back to the road analogy, towards the end of the film, Max Mosley, who played a key role in some of the changes said that about 3,000 people die on public roads worldwide. Even with an improvement of just 1% we would save 30 people a day, and he hoped some of the advances in safety that had filtered down from Formula One to commercial vehicles had exceeded this. Small increments in safety can save many lives when the scales are massive – so even an improvement of just 1% across all treatment would positively impact a huge number of people in healthcare.
Here we come back to my original tweet, which compared ‘getting the NHS up to aviation safety levels’ to ‘getting public roads up to Formula One safety levels’. No drivers have died behind the wheel of a Formula One car since Senna in 1994, but thousands die everyday on public roads. Can public roads reach the safety levels of Formula One? Probably not. Is the NHS more like a high-class Formula One race that is well resourced, a short discrete race, and highly organised; or is it more like public roads that are messy, are continuously active, and unpredictable? Whatever side of the fence you fall on, and it may be that some parts of healthcare are more like one than the other, we should find solace in the advances that have been made in other domains, e.g. airline and F1; and the small advances that have had huge impacts on a mass scale, e.g. airbags and seat belts. We need to be realistic about the comparisons we make, but we should also be optimistic and present a positive message for change too.
If we are in a safety revolution for the NHS, and someone makes a documentary like ‘Life on the Limit’ for healthcare, who and what would be part of the story? Key parts of the story could potentially be:
- Martin Bromiley’s fight to promote human factors thinking in healthcare and establishing the CHFG which is reported here: http://www.newstatesman.com/2014/05/how-mistakes-can-save-lives#
- Atul Gawande’s Checklist Manifesto which promotes the use of checklists for safer surgery
- Kimberly Hiatt’s suicide after she accidentally gave an overdose to a baby
- The tragic death of Wayne Jowett who received an intravenous drug intrathecally.
- The Mid Staffs hospital scandal where excess deaths and poor treatment were reported.
- The To Err is Human: Building a Safer Health System report which concluded that between 44,000 to 98,000 people die each year as a result of preventable medical errors.
What else would you add? What would the story look like? How does it end?
PPI Project For Carers with Experience of Home Enteral Feeding: Experiences, issues and tips & tricks
This is a Patient and Public Involvement (PPI) project: we would like carers to help us refine a survey, advise on how to distribute it, and comment on the findings. This is to help us make the research questions more relevant and meaningful.
We would like to speak to carers who have experience of home enteral feeding. Home enteral feeding is normally for patients who have a problem with feeding through their mouth and down their throat, so nutrients are delivered straight to the stomach. This might be through a tube in their nose (e.g. nasogastric or NG tubes), or a tube that goes into their tummy (e.g. PEG tubes).
We want to find out more about experiences, issues and tips & tricks focused on:
- A) The usability of the equipment that is used, e.g. are the pumps easy or hard to programme, do they alarm a lot, do they disturb you at night, do they give error messages that you cannot understand, and are blockages frequent?
- B) Issues with taking medication, e.g. have you ever had difficulties trying to give medication because you were given pills, or maybe some medication is more difficult to give than others?
The project is divided into three activities that we would like to run over Summer and Autumn of 2014:
- Activity 1) We will draft a survey and send it to our Carer Advisory Group for feedback on whether the questions are the right ones and to check how they are worded. This should take 1-2hrs.
- Activity 2) We will disseminate the survey. This should take about 30mins.
- Activity 3) After analysing the survey results we will share them with our Carer Advisory Group. This should take 1-2hrs.
How can I take part?
We would like carers with relevant experience of home enteral feeding to be part of our Carer Advisory Group, and to fill out the survey that is developed. If you would like to take part, or just would like further information then please get in touch.
Why should I take part?
There has been very little research on the experiences of carers who have had to deal with home enteral feeding. We would like to find out more about the issues that carers have faced, particularly in terms of the usability of the pumps and the equipment that is used and in terms of giving medication. We would also like to investigate the tips & tricks that carers develop to cope with these issues, e.g. are blockages experienced and how are these dealt with. What would you tell someone who was just starting out in this area? These experiences could help new carers. We can also disseminate our research to service managers and manufacturers of equipment.
How will I be compensated for my time?
As a thank-you for your input people in the Carer Advisory Group will be given £50 for Activity 1 and Activity 3, so £100 in total.
People who fill out the survey in Activity 2 will be entered into a prize draw – details to follow.
In both cases please get in touch.
Who is funding and organising the project?
This project is being organised by Dominic Furniss and Mine Orlu Gul. This project is funded by University College London – Grand Challenges of Human Wellbeing small grant. A project summary page can be found here.
Please contact Dominic Furniss if you would like more information.
My role on CHI+MED is primarily to do field studies in hospitals, to investigate the design and use of medical devices by asking questions like: are they usable? are there design issues with devices? how could they be improved? One of the big differences of doing this sort of research in healthcare, rather than in other domains, is trying to negotiate access to NHS staff, patients and contexts for research purposes. Unfortunately, this puts off good researchers working in this area.
Generally you need to fill out very lengthy forms to get approval from a Research Ethics Committee (REC), you need separate documentation to get personal access – something like a research passport; and local R&D approval at the site you want to enter. Different people give different views about what is required. Many forms are slightly different repetitive versions of other forms. There always seems to be some surprise, bug, hiccup or something you have forgotten to delay progress and to generate more administrative work. Days turn into weeks, weeks turn into months, and it seems months go on and on.
This process is notoriously a bit of a headache – ‘a place that sends you mad’ which we’ll come to in the Asterix cartoon. Here are some nuggets to demonstrate what it is like:
- For one project, after going through all access hoops described above, some suggested it was all unnecessary, i.e. we should have sought to gain access via an audit route rather than getting NHS research ethics.
- A friend of mine doing the same thing was advised to speak to person A to get through the next step. They phoned and spoke to person B who explained that person A was on holiday for two weeks. They waited. When person A was back they spoke to them and he explained that he really needed to speak to person B, who of course was there all along.
- I was advised to send forms through and follow-up the following week. I sent the forms through and phoned the next week and the person that was dealing with this request had left – so I was left in limbo.
- I was advised to phone the REC to book an appointment and get a REC number before getting authorisation on my IRAS form – once you have authorisation the forms are locked. The REC people said get the authorisations first. I brought up the fact that doing it this way meant that the document was locked and so I couldn’t enter my REC number on the system. The lady suggested I print it out, write it on the form by hand, and then scan it in!
- I’m now dealing with a separate body for NIHR CSP. They said don’t active the SSI form before they give the go ahead, instead email them everything first. The JRO said this duplicates all the work and that I shouldn’t need to do this. However, I’m just doing this to keep the CSP people happy otherwise I suspect it will cause them some headache, which in the end will probably cause me more headache.
- Some hospitals require CRB checks, some immunisations, some very little, some require GCP training, and all of it seems a bit random.
- One colleague thought he had done everything, then someone decided all his documentation needed to be peer reviewed so he was back to the drawing board. He only wanted to interview three managers in three different hospitals about purchasing – 6 months later he’s still not achieved access.
- Another colleague was through, at least she thought she was, but not quite. The hospital required a change to some forms at the R&D stage, so she had to go back and get an amendment from the REC. She’s an MSc student who has been working on trying to get access for 6 months or so.
- I was told that our whole project team would need GCP training for this new project we are starting – even researchers that would never step foot inside the hospital. I raised this with someone else who said it was wrong and they found documentation to support this view. We don’t have to because we’re a non-CTIMP study. Again, more work that wasn’t strictly necessary, misinformation and hoop jumping.
There’s lots of documentation and advice on these processes, although I imagine only a few people have a real grasp of the rules and workarounds that go on. My favourite resource for getting a feel for what this process is like sometimes is captured nicely in this video where Asterix is given the rather simple administrative task of getting Permit A 38 (it also serves as a bit of light relief):
If you’re working in this area you might find our new books interesting. They are aimed at researchers that are new to healthcare and just coming into it, although they would be a good source of reflection and debate for more seasoned researchers too. The first volume covers 12 case studies of researchers carrying out HCI and human factors fieldwork in healthcare. The second volume will be published in summer 2014.
It’s great to finally reach this stage where the first volume of these books is available on Amazon. This one contains 12 case studies from HCI and human factors researchers who detail their experiences of doing fieldwork in healthcare (warts and all). The companion volume, which will be published this summer, will synthesise advice from these experience. I really hope that these books fulfil their aim of being a great resource for researchers and practitioners that are starting to do this sort of work in healthcare. We hope it goes someway towards making this important area of study more accessible for graduates, as well as providing substance for reflection and debate for more experienced researchers and tutors.
Originally posted on hci.healthcare.fieldwork:
We are pleased to announce that the first HCI Healthcare Fieldwork volume, “Fieldwork for Healthcare: Case Studies Investigating Human Factors in Computing Systems”, is now available through Amazon.
It will also be available for purchase at CHI 2014 in Toronto where you can also pre-register for the second volume, “Fieldwork for Healthcare: Guidance Investigating Human Factors in Computing Systems.”
This video explains the sort of research I have been involved in and why: it highlights that relatively small errors in medical device design can have big consequences; in terms of psychology people quickly piece together signals from their environment with their expectations; the default position seems to be suspend and investigate individuals rather than look at the arrangement and design of the broader system in which they work. James Reason (2000) says this about system changes, “We cannot change the human condition, but we can change the conditions under which humans work.” It also starts to get at the sticky subject of blame in healthcare…
Originally posted on chi+med blog:
from MedStar Health.
Here’s a short video that nicely illustrates how a systems approach can be more effective in improving patient safety.
A patient’s blood glucose level was actually extremely low but the blood glucose meter the nurse was reading indicated the exact opposite. To try and bring the ‘high’ level down the nurse gave the patient some insulin, which of course just lowered it further. The patient became unresponsive and was taken to intensive care where the problem was spotted – fortunately both the patient and their blood glucose levels recovered.
When a second nurse experienced a similar problem with a blood glucose meter the initial response resulted in one of the nurses being placed under a disciplinary investigation with threat of suspension. This shook the nurse’s confidence, yet didn’t seem to solve the problem.
Hospital staff asked a…
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