This may be of interest...

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Nine tips on how to safely administer multiple intravenous (IV) medications will be the focus of a free webinar to be held on Wednesday, May 30 at 2 pm Eastern time. Three study authors—two human factors engineers and a nurse—will be offering detailed advice on how to identify and mitigate the risks associated with the administration of multiple IV infusions based on their recent findings.

Multiple IV Infusion Safety Webinar
Date: Wednesday, May 30
Time: 2:00-3:00 pm Eastern  [edit: 7pm-8pm British Summer Time]
Register here for this complimentary session today.

The recommendations are intended for all inpatient and outpatient care areas where multiple IV infusions are administered to patients. The webinar is targeted at nurses, senior hospital management, clinical managers, educators and practice leaders, and those responsible for medical equipment procurement decisions.
 
Administering multiple IV infusions is a complex task and therefore prone to a variety of errors, the study authors found. Such infusions are often delivered with large volume pumps through a combination of primary and secondary “piggyback” infusions on multiple pumps and channels. Potential errors include physical line set-up errors and mix-ups of infusion lines, bags, and pumps. For the patient, this could mean receiving an incorrect dose, at the wrong time, with harmful consequences.

The recommendations were developed by the Health Technology Safety Research Team at the University Health Network, under a grant from Health Quality Ontario and in collaboration with the Institute for Safe Medicine Practices Canada (ISMP Canada) with support also from the Ontario Ministry of Health and Long-Term Care. Study details can be found at www.ehealthinnovation.org/?q=node/523.
 
Featured speakers will be Andrea Cassano-Piché and Mark Fan, both human factors engineers with University Health Network, and Christine Koczmara, RN, a senior analyst with ISMP Canada.

The webinar is being offered jointly by the AAMI Foundation’s Healthcare Technology Safety Institute (www.aami.org/htsi), the Infusion Nurses Society (www.ins1.org), ISMP (ismp.org), and ISMP Canada (www.ismp-canada.org). For further information, email htsi@aami.org or call (703) 253-8297.

"The Safe Interaction Summit focuses on medical, psychological and human computer interaction background to human error in safety critical fields. The summit leaders are world experts, and will work with participants to drive the field forward, including supporting collaborative research and underlying methodologies, particularly exploring the interdisciplinary issues and conflicts.

This summit will build up a platform where academic and industrial researchers working in combined fields can come together to review their work and find ways to improve quality and impact in the design of interactive devices in safety critical fields."

1st Safe Interaction Summit - CHI+MED

Date and time
9am-5.30pm, Thursday 7th June 2012

Venue
Fudan University, Shanghai, P.R. China

Agenda
09:00 - 09:40 Registration and networking
09:40 - 10:40 Welcome and introduction - Prof Harold Thimbleby
10:40 - 12:40 Round table research showcase
12:40 - 14:00 Lunch and networking
14:00 - 15:30 Commitment and plans for high level summit (workshop and conference) in 2013
15:30 - 16:00 Coffee break and networking
16:00 - 17:30 Round table discussion

Who should attend?

• Researchers or students in the field of computer science, psychology, industrial design, medicine or other relevant fields
• Safety critical interactive device designers, developers and manufacturers

How to register
The event is in English. A limited number of seats are free of charge.
Due to limited space available, please send your registration request to yunqiu.li@swansea.ac.uk along with a short biography. We will get back to you to confirm your seat as soon as we can.

Organizers

• CHI+MED
• Future Interaction Technology Laboratory (FIT lab), Swansea University
• International Design Centre, Zhejiang University - The Hong Kong Polytechnic University, China
• Human Computer Interaction Laboratory, Kochi University of Technology, Japan.

Flyers
In English (PDF, 282kb) and Chinese (PDF, 335kb)

Sarah Wiseman - Bright Club

Video orginally posted on Dr Anna Cox's blog

Bright Club is a monthly UCL science stand-up comedy event in London and Sarah Wiseman (see her previous blog post here) recently took part with a short , giving a short stand-up presentation on her PhD research into number entry systems used in medical devices, potential errors in entering numbers on devices (and avoiding them).

Further watching
UCLIC's Dom Furniss gave a bitesize lecture at UCL on "The Comedy of (Human) Error and Resilience"

Further reading
NASA's metric confusion caused Mars orbiter loss CNN.com website (30 September 1999)
http://edition.cnn.com/TECH/space/9909/30/mars.metric/
"NASA lost a $125 million Mars orbiter because one engineering team used metric units while another used English units for a key spacecraft operation, according to a review finding released Thursday."

Designing number entry systems for medical devices CHI+MED website
http://www.chi-med.ac.uk/researchers/numberentry.php

City University’s Centre for Human Interaction Design is having an open day on Thursday 12 April 2012 from 1-6pm.

More information including registration details below; the text comes from http://www.city.ac.uk/informatics/school-organisation/centre-for-human-computer-interaction-design

You can also follow them on Twitter at @cityuni_hcid

The EPSRC-funded chi+med project is taking place over four universities (City University, Queen Mary University of London, Swansea University and UCL (University College London)) and two hospitals (Royal Free, London and Singleton Hospital in Swansea) and the people working on the chi+med project at City are Dr George Buchanan and Jonathan Day (PhD student).

Our full list of researchers and staff can be found here http://www.chi-med.ac.uk/about/chimedteam.php

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Centre for Human Computer Interaction Design

The Centre for HCI Design is the elite Human-Computer Interaction group in London and we take great pride in our outstanding research, teaching and consultancy & business services. Our prime focus is the relationship between people and innovative technology with the aim of creating more useful and usable systems.

Human Computer Interaction Design - hcid2012

Date: Thursday 12 April 2012
Time: 1.00 - 6.00PM

Annual Open Day with tours, talks and workshops

Register here http://hcid.soi.city.ac.uk/cityinteractionlab/blog/city-university-london-hcid-open-day-2012/

 

There are two things here that might be of interest. The first is the announcement about NAMDET (The National Association of Medical Devices Educators and Trainers) and their website, the second is the existence of the CHAIN mailing list, which is

"CHAIN - Contact, Help, Advice and Information Network – is an online network for people working in health and social care. It is based around specific areas of interest, and gives people a simple and informal way of contacting each other to exchange ideas and share knowledge.  For more information on CHAIN and joining the network please visit website: http://chain.ulcc.ac.uk/chain/index.html"

Each message is sent to a targeted group (people who've ticked a box to say they're interested in a particular topic) and this one was sent to people who expressed an interest in medical devices, equipment and medical physics. You can find out more about CHAIN from the link above, and NAMDET from http://www.namdet.org
 

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The National Association of Medical Devices Educators and Trainers (NAMDET) was established in response to requests from healthcare professionals and in particular, from Medical Device Trainers. As the association for medical device educators and trainers. NAMDET aims to improve the patient experience through its support for those professionals and their employing organisations across the range of health and social care.

NAMDET’s Objectives

Our objectives are to :
• Raise the status and standing of Medical Device Trainers and Educators
• Provide a forum for mutual support and assistance between members
• Represent the consensus views and opinions of members at regional and national level
• Inform and improve national policy and the regulatory landscape by communicating NAMDET member positions on issues of importance
• Positively contribute to reducing adverse medical device incidents

Membership is free and open to anyone working within healthcare and with Medical Devices who has an interest in Medical Device Education and Training. This includes, but is not exclusive to, the following Groups:-

• Nurses
• Doctors
• Operating Department Assistants
• Risk and Governance Managers
• Operational Managers, with a responsibility for medical devices
• Estates Managers
• EBME
• Community Equipment Service Providers
• Medical Device Coordinators
• Medical Device Trainers
• Key skills Trainers
• Medical Physics staff

Please visit the NAMDET website http://www.namdet.org

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If you would like to publicise information on the CHAIN Network please email your request to:  enquiries@chain-network.org.uk

Dom Furniss gave a short talk at UCL on 9 March 2012 on some of his CHI+MED work on human error and resilience. The audio of the talk is now available (the video is embedded above or you can watch it along with other videos over at our YouTube channel) and Dom has written a little more about the presentation over at his blog.

The aims of Dom's talk were to
(1) "raise awareness about the pervasiveness and importance of human error" - in short, we all make mistakes
and (2) "to introduce concepts for thinking more deeply about cognitive resilience."

Suitably, for blogging about this on Pi Day, Dom refers in his talk to a resilient strategy he developed when having a Fray Bentos steak and mushroom pie...

More about the talk details here.

 

Designing for the task: what numbers are really used in hospitals?
Sarah Wiseman (PhD student, UCLIC)

If you’ve ever played Scrabble or Words With Friends you’ll know that each letter on the board has a different scoring value. This is decided by the frequency of that letter in the English language; the more frequent a letter, the easier it is to place on the board and thus fewer points are awarded for using it. A while ago I started to wonder how you might assign points to numbers, instead of letters. Do some digits occur more frequently than others or are they all equally likely?

The reason I wanted to know this was not because I was designing a new number-based Scrabble-type game, but because I wanted to know more about error rates in number entry. We know that there are different error rates associated with the frequency of a letter, but we don’t know if this applies to numbers. I wanted to find out. The first step was to look at a big set of numbers and see if there were any differences in the frequency of digits.

I’m interested in number entry in the medical domain so the big set of numbers I chose to look at were the log files from 32 drug-infusion pumps, used in different wards in a hospital.

These logs recorded lots of information about the pump: when alarms had gone off, when the pump had been started and stopped, and also what the current fluid volume and rate of infusion were. It was these two pieces of information that I was interested in; these were the numbers that the medical worker would have had to type in to set the infusion going.

After analysing all the pumps I got the following results, you can see that there was a lot of variation in the number of times each digit was used.

The 0 was by far the most common digit; it was used three times more than any other digit. The digits 1, 2 and 5 were also used more often than you’d expect on average.

Ignoring the decimal point, there were more interesting findings when I looked at the frequency of digits on each of the wards. You can see the graph of digits for each of the wards below.

You can see how each ward generally follows the same sort of pattern overall, however, in the surgical ward you can see that suddenly the digit 9 becomes the most frequent. What might be causing that?

We don’t know the circumstances under which these pumps were programmed, but we can start to guess at why we see this abundance of 9s in the surgical ward.  If you were programming an infusion and wanted to administer the medication to the patient as quickly as possible what would you do? You might set the pump to work as fast as it can, by typing in the highest number you can, which in this case would mean filling the numeric display with the number 9.

With this sort of information, we might think about how we can better design the number entry interface to match the tasks that are being completed on it. This happens in other areas of design, often on smart phones. For example, when entering an email address, the keyboard on some smart phones changes to provide you with the @ symbol, which is normally hidden in a punctuation menu and harder to get to. Equally when entering a web address (URL) in the browser address bar, the keyboard might change to give you a ‘.com’ button, because in this situation, it’s very likely you’re going to need to type that. Both of these design alterations involve changing the interface, to meet the needs of the task.

Applying this idea to infusion pumps we might want to add a button to infusion pumps that automatically sets the pump to the maximum to stop people needing to keep pressing the 9 key. Or, we could make the popular keys easier to access on the interface or add buttons for common digit combinations, like they have in this optician’s interface (glasses prescriptions end in .00, .25, .50 or .75).

This is just the beginning of this line of research. We now need to know which interfaces suit these types of numbers. And we can also begin to investigate whether users make the same types of frequency related errors with digits and numbers as they do with letters and words.  It will also be interesting to see if any other wards have unique patterns of digits, or indeed if these patterns are seen in different hospitals.

See also
Sarah Wiseman on digit distribution: analysis of numbers entered into infusion pumps (CHI+MED blog, 7 December 2011).

 

UPDATED 21 March 2012: Patient Safety and Medication Error Workshop - Masterclass on research in clinical error on 24th and 25th March 2012 at Nottingham. The Masterclass Workshop is aimed at researchers working in a combination of medical, psychological and HCI background to clinical human error or related fields.

 

CHI+MED is hosting a two day workshop on medical devices and patient safety in Nottingham, on the weekend of 24/25 March 2012, it’s free to attend.

“Patient safety and medication error” is aimed at:

• Academic researchers who are working on or interested in: Patient Safety; Medication Errors; Incident Reporting and Learning;
• Healthcare practitioners or representatives from relevant organisations;
• Patients or representatives from relevant organisations;
• Human Factors researchers or members from relevant organisations.

Visit the Nottingham workshop homepage | About the workshop

What: Patient Safety and Medication Error workshop
When: Saturday 24 and Sunday 25 March 2012
Where: Nottingham
Contact: Victoria Hurst – V.L.Hurst AT swansea.ac.uk

Information on CHI+MED’s previous workshops can be found here.

Here's a fairly simple machine but I think it's a rather good example of the ways in which poor design can make it more likely that the user will make a mistake.

On the left there is a panel with four buttons with an arrow pointing to something on the screen. Pressing a particular arrow activates the option on the screen next to it. Or at least it should...

Unfortunately, in the example below the match-up between the buttons and the options has come unstuck. Which button should you press to get £30? You might feel a bit short-changed if you press the button that's next to it.

Picture credit: Cash machine buttons

Who knows how to work the DVD player in your house?

What information do they need to get it working? Do they read the instruction manual or just work it out from the machine itself? How easy is it to work out what the buttons do? 

 

Come and test the buttons on our machines and see which types of design make it easier for people to use them. Can you design a better button?

 

A delegation of chi+med scientists, some microwaves, popping corn (in three different flavours!), clock radios and packs of playing cards will be appearing at Hove Park Upper School tomorrow (Sunday 12 February 2012) from 10 to 5pm.

 

We'll be showing off some card tricks, road testing clock radios (how many buttons do you have to press to set the alarm?) and racing microwaves (whose popcorn will pop first?).

 

Devices like these use buttons with brief instructions on them - they might be a word or a picture. But are they easy to understand and do they help you use the machine, or just confuse you? 

Picture credit: Dr Dominic Furniss

 

Doctors and nurses also use machines to give medicines to their patients. Sometimes they need to give information to the machine (for example telling it how much drug to give) and sometimes they need to get information from the machine (for example finding out how long the machine's battery is going to last).

 

Come and see if you can learn and understand the pictures that doctors and nurses might see on the medical devices they use - and enter our competition to see if you can design a better picture (the winner will be sent a £10 Amazon voucher).