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The application of the principles, methods and data of HFE will result in significant reductions in the rate of preventable errors in the health care facilities, hospitals and clinics. The application of HFE to health care systems will be based on existing theories of human error causation in the HFE discipline. Specifically, HFE theory holds that, while errors can be attributed to deficiencies on the part of the human (slips, lapses, inattention, fatigue, insufficient skill or knowledge, etc.) the majority of errors are due to factors external to the individual, and, as such, are preventable. These external factors can be classified as situational factors and design factors.
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Situational factors in medical errors include those aspects of the operational setting, other than design, which influence human error incidence. These include: task difficulty, time constraints, interfering activities, poor communications, and excessive workloads. Together the situational factors and the design factors constitute the human-systems interface.
In terms of avoiding human errors, the influence of personnel factors that contribute to error potential (fatigue, impairment, confusion, etc.) can be reduced through attention to requirements for "fitness for duty". Fitness for duty requires that the human in the system be fully competent, capable, rested, attentive, and unimpaired. Ensuring fitness for duty is not an objective that is achieved once and then forgotten. Rather, it requires a sustained effort of engaging the individual’s cognitive capabilities, vigilance, and attention through decision aiding, and intelligent prompting and cueing.
The influence of situational and design factors in error causation can be reduced through attention to the effective design and implementation of human-system interfaces. Again, these are the interfaces between the human practitioner and the other elements of the medical system.
The focus of Carlow’s approach is on improving patient safety and staff safety in the conduct of health care. A series of iterative steps are required to increase safety.
The first step is to establish that errors do exist in the health care process. Secondly, it must be determined that near misses as well as errors do occur in the process, and that these can be recorded. Third, it must be determined that the errors are preventable, and what tasks are candidates for improvements or redesign. Fourth, where errors are not preventable, the system will be designed to safeguard against injury to patients or staff. Finally, by using human factors engineering methods to decompose the error-prone tasks and subsequently to maximize human cognitive (attentional and decision-making) capabilities for these tasks, patient safety and staff safety will be improved.
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The objective of human factors engineering is to design human-machine interfaces to reduce the incidence and impact of human error, make computer programs usable by persons with little or no computer literacy, simplify complex activities, provide needed skill through training, and reduce the incidence of accidents and health hazards.
Benefits
When applied to health care systems and facilities, such as hospitals and long term care facilities, human factors engineering has a number of significant benefits, including:
• improved safety of patients and staff through improved design of human-machine and human-facility interfaces;
• improved staff productivity through improved working conditions, including more efficient, effective, and safe workstations;
• improved design of hardware, software, procedures, practices, and tasks to reduce the incidence and impact of human errors;
• orientation and training of staff in behavioral techniques to reduce the incidence of human errors;
• reduced operating costs through appropriate use of technology and trained personnel, and reduction of the incidence of billing errors;
• simplification of procedures and operations;
• improved computer program usability to enable the health care specialist or administrator to easily and reliably conduct required tasks;
• improved training programs and materials;
• improved information management and decision making by system personnel.
Human factors engineering has significant effects on system and facility reliability, usability, safety, effectiveness, and affordability.
Reliability of Health Care Systems and Facilities
Human factors engineering in system or facility design results in increases in system reliability since the major contributor to system reliability is human reliability. A major concern in hospital systems is the high incidence and severe impact of human error. The National Institute of Medicine Report on Error in Health Care (1999) calls for HF interventions since a major objective of human factors engineering is to reduce the incidence and impact of human errors. For example,the use of computers in patient care which can provide real-time information about prior interventions, test results,etc. can sharply reduce the likelihood of inappropriate interventions. Carlow is currently addressing issues of error reduction in cancer care in collaboration with several cancer hospitals.
The human factors engineering (HFE) concern for reducing the incidence of human error extends beyond the issues of patient safety to also include such hospital problems as errors in billing. Millions of dollars are being lost each year in US hospitals due to the high rate of billing errors, which results in an inability to collect on the costs of hospital services. In the $900 billion US health care industry, complex billing procedures are pervasive. Because of the diversity of health problems, the variability of funding sources, and the frequency of inter-institutional and inter-professional care arrangements, billing error is frequently encountered. The causes of medical billing errors are basically threefold: human slips (typographical errors), inadequate human computer interface (HCI) design, and ineffective billing procedures. HFE addresses methods to avoid each of these problem areas in system design/redesign, and to control the occurrence of billing errors due to each causal factor through improved procedures, decision aids, and training. While billing complexity and resultant loss of income may not be as major a problem in Ireland as it is in the US, nonetheless it may be an important area for examination.
Usability of Health Care Systems and Facilities
Human factors engineering improves system usability. Computer systems and programs are continually being procured for hospital applications which are extremely difficult for non-computer professionals to effectively use. The requirement for usability was usually not addressed in the development of these programs. Where computer-based systems are usable, the probability of human error, time to perform tasks, and the time to train, are all reduced, tasks are simplified, and users are more satisfied. A system is usable to the extent that: human-computer interfaces are designed in accordance with user cognitive capabilities; displays are standardized and are easily read and interpreted; the user is always aware of where he or she is in a program; procedures are logically consistent; documentation is clear and readable; on-line help is available and responsive; and the user understands how to navigate through a program to retrieve needed information.
Carlow has carried out a review of software development and adaptation process for the Western Health Board of Ireland. Since the great majority of software products for health care applications are developed in the US, Irish health care systems have had to engage in strategies to adapt such software for use in hospitals and other health systems. In this situation staff training for use of such adapted technologies is of central importance. The Carlow review for the IT staff at WHB corroborated the need for HF interventions in the software purchasing, adaptation, and training processes.
A major segment of Carlow’s HFE business over the years has been optimizing the human performance side of Informatics, by designing human-computer interfaces for ease of use. Carlow personnel have been intensely involved in design of human interfaces for every NASA manned space mission since the Gemini program. Carlow has supported NASA Goddard Spaceflight Center in design of human computer interfaces and advanced displays for control of a number of unmanned spacecraft missions. Carlow is currently supporting BP/AMOCO in making improvements to human computer interfaces (HCI) on exploration drill ships and platforms. Carlow is assisting the U.S. Naval Sea Systems Command in developing advanced display techniques for ensuring that humans can interact with automation in future ship systems. Carlow is supporting the Naval Air Systems Command in developing research and technology development programs for robotics, automation and advanced control techniques for future aircraft carriers. Carlow is supporting the U.S. Coast Guard in defining a standard design process for integrating HFE in future Coast Guard systems acquisition. Carlow provided HCI usability evaluation support to IBM, for new PC programs, and to the Consumer Products Safety Commission for specialized computer interfaces. Carlow has supported the Nuclear Regulatory Commission and Brookhaven National Laboratories in developing design guidelines for advanced computer-based human interfaces for control systems of nuclear power plants. Carlow has supported the Defense Advanced Research Projects Agency (DARPA) and General Electric in defining human computer interface requirements in the development of high definition TV and flat screen displays. Carlow has supported the Federal Aviation Administration (FAA)in the development and evaluation of advanced HCI concepts for air traffic control and air support facilities. Carlow has also supported the FAA in development of a conceptual expert system for evaluating flight crew on cockpit resource management factors. Carlow has developed graphic user interface (GUI) concepts and criteria for a number of applications, including the Internal Revenue Service, Navy command and control systems, robotic control systems, offshore control systems, medical device manufacturing systems, and medication compliance memory aids for the elderly.
Safety and Effectiveness of Health Care Systems and Facilities
The inclusion of human factors engineering in hospital system design directly impacts the safety and performance effectiveness of patients and staff. Human factors engineering simplifies jobs and eliminates hazardous situations. Through design of equipment, jobs, environments, procedures, and training, human factors engineering directly impacts the safety, productivity, and performance effectiveness of people. As an example of how human factors engineering contributes to personnel health, Carlow has assessed job factors which contribute to carpel tunnel syndrome. It has, for example, determined how to modify jobs and job performance char-acteristics of railway yard workers to reduce the impact of cumulative stress disorders. In another important area of health care, medication use, Carlow examined the issue of medication regimen compliance by elders and developed a prototype design for an electronic memory aid/medication dispensing device for use by elders , through a National Institutes of Health funded project
Affordability of Health Care Systems and Facilities
Human factors engineering impacts the affordability of health care systems and facilities through its effect on operational costs. Personnel costs constitute a major proportion of the costs of operating a system such as a hospital. These include costs of personnel selection, training, and support. Human factors engineering reduces time to train, and through proper assessment of technology requirements may also impact on employee numbers and skill levels of personnel. Current Carlow research on the topic of technology replacement of personnel functions is assisting in the reduction of personnel requirements in transport vessels and U.S. Navy ships. The Carlow tools(for assessment of the technology and personnel requirements) developed in that process, could be utilized in health care settings with appropriate adjustments for the staff intensive nature of health care and its human contact requirements.
Human Factors Engineering reduces human errors and accidents, and the costs associated with them. Human factors engineering application results in avoidance of the costs associated with system unavailability, thereby increasing the revenues accrued through sustained operation. Carlow is currently applying HFE to staff interaction with patients in Special Care Units of Nursing Homes (funded by National Institute on Aging). This project has resulted in a prototype computerized staff training tool which will enhance patient autonomy. It will also enhance training flexibility even allowing for use of home computers by trainees. The project has also generated lessons on staff safety which are incorporated in the training tool. Currently NIH is reviewing a Phase II project to further advance this training tool.
In Ireland, Carlow Associates has recently conducted evaluations of safety, quality of life and communications in long term care nursing homes for the Western Health Board (1999). For the EU, Carlow conducted two research projects in 1999, one directed at improving the affordability of shipping in Europe (the THALASSES project), and another focused on design of access and safety solutions for elders and persons with disabilities who are passengers on European ferries and cruise ships (the HANDIAMI project). Health care institutions must also offer easy and safe access for frail persons.
Carlow Services
The types of services offered by Carlow International include:
• HFE residential design and assessment to enhance patient safety ;
• tailoring of ADA requirements for persons with disabilities;
• Computerized Training tools for Nurse Aides and other personnel;
• techniques to increase the productivity of the older worker;
• techniques to enhance the safety and capability of the elderly or persons with disabilities using public transportation;
• techniques to enhance the safety of the elderly or disabled driver;
• techniques to enhance the safety and capability of the patient in the clinic or hospital;
• techniques to enhance productivity in the use and operation of computers and software systems;
• design concepts and criteria to enhance the usability, reliability, and safety of medical devices;
• HFE design and evaluation of health care systems and equipment for safety and usability by professionals, patient users and users with disabilities;
• redesign of jobs to reduce the incidence and impact of cumulative stress injuries;
• development of user-friendly management information systems.
• Error Reduction Methods in Cancer Care
