##### Human Factors Engineering & Patient Safety

# Instructors Guide

By John Gosbee, MD

VA National Center for Patient Safety

<John.Gosbee@med.va.gov> 734-930-5893 www.patientsafety.gov

##### Background and Rationale

Human factors engineering and design problems are key aspects of most
adverse events in healthcare. Not learning these basics would be like
infection control professionals not knowing about microbiology.
Unfortunately many of your learners and colleagues are going to know
very little about HFE, and even less about how best to teach it. There
are introductory books about HFE that have found to be less than useful
for slightly interested audiences (Sojourner, 1993). Parts of this
teaching session have been successfully used by university professors
(Sojourner) for bored introductory HFE students. Also, HFE practitioners
teaching the basics in "tough" industry settings have provided some of
the demonstrations and "games" in this module that make HFE concepts
more accessible (Shapiro, 2001).

For a nice introduction to how our world is filled with HFE examples,
see a web site called "Bad Human Factors Design" by Darnell, or read the
book "Design of Everyday Things" by Norman.

##### Objectives

1\) Understand how human factors engineering (HFE) is a useful
problem-solving approach for patient safety

2\) Introduce how demonstration of HFE principles helps

-   Turn learner's brains around 180 degrees

-   At the same time teach them safety content

3\) Demonstrate how HFE helps improve analysis and development of
lasting remedies (interventions)

##### Applicability

This is applicable to all residents, medical students, nursing students,
and other learners who will likely never get to hear about the science
and applicability of HFE anywhere else. You may find one in a hundred
who has taken HFE 101...but likely they will not have seen these
demonstrations and will appreciate the new tools to spread the word.

##### Constraints and Lessons Learned

These demonstrations are easier than you think. Making the
clinical-pathological correlation is much tougher than you think!
Consider watching how I have tried to present some of the example cases
in the accompanying video (developed for VA new employee orientation)
and another video of me carrying out the demonstrations and ensuing
discussion.

####### [Outline]{.underline}

##### Basics of Human Factors Engineering

-   Formal definition

-   Working definition

-   Conceptual model

##### An alternative view of human error

\- The "flip-side" of human performance

##### Brief case studies with medical devices and software systems

-   Ideally with props

-   Could be materials or systems in any room or medical setting

##### Vigilance experiment

-   Radar screen as a teaching tool

-   Changing design to address all human senses

-   Correlation with clinical monitoring/vigilance tasks (telemetry work
    stations)

## Variability in simple interpretation

-   Demonstration with "E" made of "X"s

-   Patient safety example (telemetry off -- it is off and needs to be
    turned on, or take it off)

##### Selective attention demonstration

-   With repeated words paragraph

-   Clinical example (nurses and physicians "see" different things when
    assessing patients)

##### Paired association demonstration

-   Saying "up" and hitting desk

-   Clinical example (silencing almost any alarm instinctively)

-   Patient safety example (pharmacist who hits enter key all day, then
    has to switch to space bar)

##### Stroop color demonstration

-   Colored boxes and words with mismatched final pair

-   O2 cylinder and other compressed gas color-coding examples

-   For freely available demo, see:

> <http://faculty.washington.edu/chudler/words.html#seffect> or
> <http://www.njagyouth.org/colortest.swf>

##### Overview of HFE methods

##### Heuristic evaluation and usability testing

-   Small group exercise to apply 7-9 HFE guidelines to some electronics
    in the room

-   Classic PCA usability test (before and after) example

#####  

##### HFE Role in Healthcare Vulnerability

-   Developing improved ICU alarms

-   Improving ACLS protocols

-   More reliable endoscopes

-   More usable metered dose inhalers

-   This will be developed more!

##### Organizations and efforts underway to do more

-   FDA (human factors department)

-   University of Wisconsin (med school and industrial engineering
    school)

-   Catholic University (teaches HFE to all BMEs)

-   National Cancer Institute
    ([www.usability.gov](http://www.usability.gov/) )

-   VA National Center for Patient Safety (core competency)

**[Human Factors Engineering References]{.underline}**

Bridger RS, Poluta MA. Ergonomics: Introducing the human factor into the
clinical setting. *J of Clinical Engineering* 1998; 23: 180-188.

Gosbee, J.W. (1999). Human Factors Engineering is the Basis for a
Practical Error-in-Medicine Curriculum. First Workshop on Human Error in
Clinical Systems. Glasgow, Scotland. April 1999.
<http://www.dcs.gla.ac.uk/~johnson/papers/HECS_99/Gosbee.htm>

[Johnston WK 3rd, Low RK, Das
S.](http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12885360&dopt=Abstract)
Image converter eliminates mirror imaging during laparoscopy. *J
Endourol*. 2003 Jun;17(5):327-31.

Murff HJ, Gosbee JW, Bates DW. Human Factors Engineering and Medical

Devices. In: *Making Healthcare Safer: An Critical Analysis of Patient
Safety Practices*.

Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Evidence
Report/Technology

Assessment No. 43, AHRQ Publication No. 01-E058; July 2001. Available
a[t]{.underline} www.ahrq.[[gov]{.underline}](http://www.ahrq.gov/).

Lin, L., R. Isla, K. Doniz, H. Harkness, K.J. Vicente, and D.J. Doyle,
1998. Applying Human

Factors to the Design of Medical Equipment: Patient-controlled
Analgesia. *Journal of Clinical*

*Monitoring and Computing* 14: 253-263.

Samore M, et al. Medical device adverse events? Title? JAMA, early 2004.

Small S. Editorial about Samore article. JAMA, early 2004

Shapiro RG, Fox JE. Games to explain human factors. In *Proceedings of
the Human Factors & Ergonomics Society 45^th^ Meeting.* Santa Monica,
CA: Human Factors & Ergonomics Society, 2001.

Sojourner RJ, Aretz AJ, Vance KM. Teaching an introductory course in
human factors engineering: A successful learning experience. In
Proceedings of the Human Factors and Ergonomics Society 37th Annual
Meeting. Santa Monica, CA: Human Factors and Ergonomics Society, 1993,
pp. 456-460.

Stroop JR. Studies of interference in serial verbal reactions. *Journal
of Experimental Psychology*, 1935;18: 643-662.

Wears RL, Perry SJ. Human factors and ergonomics in the emergency
department. Ann Emerg Med. 2002;40:206-212.

Welch DL. Human error and human factors engineering in health care.
*Biomed Instrum Technol.* 1997; 31: 627-31.

**[Web Sites]{.underline}**

**Website of Human Factors Design Problems Case Studies**.
<http://www.baddesigns.com/> Examples of things that are hard to use
because they do not follow human factors principles.

**Human Factors and Ergonomics Society**. The main professional
organization in the United States. [www.hfes.org](http://www.hfes.org/)

**Food & Drug Administration Human Factors Section**. Several documents
about medical devices, errors, and the design process (e.g., "Do it By
Design")
[www.fda.gov/cdrh/humanfactors.html](http://www.fda.gov/cdrh/humanfactors.html)

**FAA On-line Tutorial on Introduction to HFE.** Good and free
interactive site to see depth and breadth in pretty good format. See
[www.hf.faa.gov/Webtraining/Intro/Intro1.htm](http://www.hf.faa.gov/Webtraining/Intro/Intro1.htm)

**Stroop Color Demonstration** and other Cognitive Psychology Demos.
Eric Chudler. University of Washington.
[faculty.washington.edu/chudler/words.html](http://faculty.washington.edu/chudler/words.html)

Kitaoka, A. and H. Ashida: Phenomenal Characteristics of the Peripheral
Drift Illusion. *Vision* Vol. 15, No.4, 261-262. 2003
<http://www.psy.ritsumei.ac.jp/~akitaoka/PDrift.pdf>

Government web site (NASA-Goddard)

This document discusses the purpose of usability testing, what it is and
what information it provides, \... and what to do with the results of
the usability testing. It is a guide to the process \[used\] in the
Software and Automation Systems Branch (Code 522) at the NASA / Goddard
Space Flight Center.

http://usability.gsfc.nasa.gov/use/Usability/Handbook_TOC.html

Consultants web site (Constantine and Lockwood, Ltd.)

\"Newly updated in 2003, this cross-referenced Q&A inventory is a place
to get specific answers or to begin learning about usage-centered design
\[and usability testing\].\"

http://www.foruse.com/questions/index.htm#7