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:
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:
What else would you add? What would the story look like? How does it end?
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:
The project is divided into three activities that we would like to run over Summer and Autumn of 2014:
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.
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.
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.
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:
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.
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…
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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