To err is not entirely human: complex technology and user cognition

Errors, misunderstandings, and inaccuracies, largeand small, are routine occurrences in our everyday activ-ities. We can live with imperfection most of the time, butwe require healthcare to be 100% error-free and medicaldevices to run ﬂawlessly. When our high expectationsare not met, society feels violated. Given the complexityof medicine, we should not be surprised that mistakesoccur. However, we can ask health care technologydesigners to play an active role in mitigating the eﬀectsof user error in medicine. Clinical medicine is a uniquelycomplex ﬁeld for which computing technology needs tobe developed according to novel and often unprecedent-ed design principles.Healthinformationtechnology(HIT)hasundoubted-ly reduced the risk of serious injury for patients duringhospital stays. However, its true potential for preventingmedical errors remains only partially realized and, para-doxically, as has been demonstrated in a recent JAMAarticle [1], some systems may even give rise to hazards oftheirown.Inourview,errorsaretheproductofcognitiveactivityinhumanadaptationtocomplexphysical,social,and cultural environments. How well the design of HITcomplementsitsintendedsettingandpurposeiscriticallyimportant for safe and eﬀective performance.There are few professional ﬁelds that pose as great achallenge to the use of computers as clinical medicine.Many safety-critical domains have been relying heavilyon automation and computing for decades. Compari-sons of healthcare and aviation often point out howinformation technology successfully transformed an en-tire industry and increased passenger safety [2]. Thedecision-making processes of a clinician, however, areperhaps more akin to those of a ﬁreﬁghter brigade com-mander than to the pilot of an airliner. In these do-mains, decisions are sometimes made with little orunreliable evidence, and changing circumstances dictatequick adjustments in the planning of actions.The recent JAMA report [1] suggesting that clinicalordering systems (CPOE) may in fact contribute to med-ical errors is a sobering reminder of the often inadequateﬁt of current computing technology to clinical work.Cautionary statements about a new kind of medical er-ror that may ensue from working with information sys-tems [3] and anecdotal evidence of the tremendouschallenges to the implementation of clinical computingtechnology [4] have appeared periodically in the researchliterature. Importantly, the JAMA study makes thecharacterization of technology-related medical errorsits central thesis. The authors are conveying their beliefthat it is the ﬂawed design and poor integration withclinical work rather than the technology itself that isat the root of its suboptimal performance. They pointout that attention needs to be given to the errors CPOEsystems can cause in addition to the errors they help toprevent and that many identiﬁed problems with CPOEimplementations could in fact be easily corrected. Thusa lack of attention to the principles of human–computerinteraction (HCI) in clinical software design is becominga critical safety hazard.Cognitive science and HCI research address many ofthe concerns that make the integration of computingand clinical practice an arduous task. Designers needto understand in detail the idiosyncrasies of the envi-ronment in which clinicians work. In a typical hospitalsetting, task ﬂow may be context-dependent, users mayfollow non-linear completion strategies due to interrup-tions, uncertainties permeate many decisions, and thehighly collaborative nature of assessment and treat-ment is critically dependent on clear and speedy