1) Human Factors Engineering (HFE) uses principles to identify and control patient safety hazards by designing systems that fit human capabilities and limitations. 2) A study redesigning a Patient Controlled Analgesia pump found the new design reduced errors by 55% and completion time by an average of 18% compared to the original design. 3) HFE considers the whole healthcare system, including training, documentation, environment, and how users interact with equipment, rooms and facilities.

1. Patient Safety and Human Factors Engineering Anne Arundel Community College Arnold, MD Carolyn Jenkins MSN, RN Spring, 2006 Adapted from John Gosbee, MD, MS VA National Center for Patient Safety [email_address] www.patientsafety.gov

3. Kyle, L. (2005). First place winner. The faces of caring: Nurses at work. 105,6.

6. Why should we care about good "Human Factors"? Human Factors applied early in the design process results in: • Increases in productivity, improved performance, and greater user satisfaction; • Reduced need for training, system maintenance, and user support; • Reduction in errors, incidents/accidents, and overall costs. http://www.hf.faa.gov/webtraining/index.htm FEDERAL AVIATION ADMINISTRATION Improved system design results in reduced costs and improved productivity/performance.

7. http://www.baddesigns.com/ Bad Design Kills

9. Radar Scope to Detect “enemy” ships

10. Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance

11. Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance

12. How can we move the curve upwards? 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance

13. Demonstration: Stroop Effect Row 1 Row 2 Row 3

14. 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

15. 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

16. Count the number of times the word “ RED ” appears in this example .

17. “ Tell the nursing student to attach the oxygen mask and tubing to the green spigot” For further info, see http:// faculty.washington.edu/chudler/words.html#seffect J. Ridley Stroop (1935) Studies of Interference in Serial Verbal Reactions. Journal of Experimental Psychology , vol 18, 643-662 Patient Safety Correlation

18. Knee-jerk vs. HFE-based Remedy Make “sure” to use the correct color Adaptor!? Better

20. HFE Example Patient Controlled Analgesia (PCA) Pump Redesign Existing Design New Design 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.

21. PCA: Programming Sequence Redesign Existing Design New Design Decision Message-guided Action Action Legend

27. "Don't worry--it always beeps when you do that!"

28. Multi-Channel Infusion Pump