Presentation
PS11 - Operationalizing the Connection Between Human Factors Engineering and Patient Safety
DescriptionThe connections between human factors and patient safety are well documented throughout the literature (e.g., Karsh, 2006; Carayon et al., 2010; Carayon et al., 2014) and captured in various training programs (e.g., World Health Organization, 2011; Watts et al., 2018). Such efforts address both Safety-I or Protective as well as Safety-II or Productive (e.g., Karsh et al., 2006) principles.
Within our healthcare operational work, we have observed examples of how patient safety activities incorporate human factors methods. One example of this integration is the use of task analysis and checklists to include elements like fatigue and distraction into Root Cause Analyses. Another is the creation of a human factors curriculum designed to instill healthcare professionals with baseline knowledge and skills such as teaching heuristic evaluation methods to clinicians. In theory, human factors activities align well with patient safety concerns because usability encompasses efficiency, effectiveness, and satisfaction, all of which can directly impact safety in the healthcare context.
In the Veterans Health Administration (VHA) human factors engineering (HFE) project space, we have introduced methods to explicitly consider safety along with usability. This has included education on patient safety concepts and techniques for human factors practitioners as well as ways to add patient safety considerations and language to existing human factors work products and templates.
This paper will describe ways in which we have added considerations of patient safety into existing human factors practices. For example, an element called “patient safety implications” was added to a standard heuristic evaluation template. Although patient safety concerns are often documented during heuristic evaluations, they are sometimes overshadowed by a large volume of other usability findings that may not tie as directly to safety. The inclusion of this field prompted the HFE evaluators to think more explicitly about risk assessment and to clearly document their concerns, which provided additional support for their recommendations to the project team.
Another project focused on the “prevention of errors” heuristic and used the structure proposed by Woods and colleagues (2012) to evaluate the design of medication administration messages and recommend revisions. This proposed structure focused on concepts from error-tolerant design, whose features include considering error prevention, reduction, detection, identification, correction, resumption of normal activities, mitigation, and surveillance (Wood & Byrne, 2002). Prompts and display elements were designed in a cognitive aid to help reviewers facilitate conversations surrounding and capture concerns about latent design issues and systems aspects that may improve or impinge on error tolerance. The presentation of these findings supported funding for significant changes to error messages in the electronic health record.
Other examples will describe incorporating a graphical depiction of use generated during a task analysis and ways in which we elicited direct provider input on patient safety concerns. We will also share feedback from project stakeholders that may help tailor HFE efforts moving forward.
Though some techniques may seem insignificant at first glance, there is real value in purposefully and systematically integrating them into HFE activities. These techniques provide us with a framework and terminology to effectively communicate concerns with stakeholders in ways that will support actions to promote usability and patient safety. By sharing these experiences, we hope to enter into conversations with other HFE practitioners that may help us all strengthen our collective efforts and deliver greater value for our patients.
References
Carayon, P. (2010). Human factors in patient safety as an innovation. Applied ergonomics, 41(5), 657-665.
Carayon, P., Wetterneck, T. B., Rivera-Rodriguez, A. J., Hundt, A. S., Hoonakker, P., Holden, R., & Gurses, A. P. (2014). Human factors systems approach to healthcare quality and patient safety. Applied ergonomics, 45(1), 14-25.
Fuller, H., Arnold, T., O’Neil, M., & Wilson, D. (2023). Activities to Promote Resilience During Health Information System Transitions. Healthcare and Medical Devices, 79:191-197.
Fuller, H., Arnold, T., Maddox, K., & Adams, K. (2022). Considerations and Strategies for Operationalizing Heuristic Evaluation Work. Healthcare and Medical Devices, 51(51).
Grissinger, M. (2010). The five rights: a destination without a map. Pharmacy and Therapeutics, 35(10), 542.
International Organization for Standards (ISO) 9241-110:2006: Ergonomics of Human-System Interaction – Dialogue Principles.
ISO 9241-11. (2018). Ergonomics of human-system interaction — Part 11: US
Karsh, B. T., Holden, R. J., Alper, S. J., & Or, C. K. L. (2006). A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. BMJ Quality & Safety, 15(suppl 1), i59-i65.
McCormick, EJ, & Sanders MS. (1982). Human factors in engineering and design. McGraw-Hill Companies.
Shneiderman B, Plaisant C. (2010). Designing the user interface: Strategies for effective human-computer interaction. Pearson Education India.
Watts, B. V., Williams, L., Mills, P. D., Paull, D. E., Cully, J. A., Gilman, S. C., & Hemphill, R. R. (2018). Curriculum development and implementation of a national interprofessional fellowship in patient safety. Journal of Patient Safety, 14(3), 127-132.
Wood, S. D., & Byrne, M. (2002). A Cognitive Approach to Designing Human Error Tolerant Interfaces. In Proceedings of the Annual Meeting of the Cognitive Science Society (Vol. 24, No. 24).
Wood S, Krieg J, Murphy D. (2012). Designing Error Dialogs and User Feedback - Guidelines. VHA Office of Informatics and Analytics. [Accessed October 4, 2021].
World Health Organization. (2011). WHO multi-professional patient safety curriculum guide. Geneva: World Health Organization.
Zhang, J., Johnson, T. R., Patel, V. L., Paige, D. L., & Kubose, T. (2003). Using usability heuristics to evaluate patient safety of medical devices. Journal of biomedical informatics, 36(1-2), 23-30.
Within our healthcare operational work, we have observed examples of how patient safety activities incorporate human factors methods. One example of this integration is the use of task analysis and checklists to include elements like fatigue and distraction into Root Cause Analyses. Another is the creation of a human factors curriculum designed to instill healthcare professionals with baseline knowledge and skills such as teaching heuristic evaluation methods to clinicians. In theory, human factors activities align well with patient safety concerns because usability encompasses efficiency, effectiveness, and satisfaction, all of which can directly impact safety in the healthcare context.
In the Veterans Health Administration (VHA) human factors engineering (HFE) project space, we have introduced methods to explicitly consider safety along with usability. This has included education on patient safety concepts and techniques for human factors practitioners as well as ways to add patient safety considerations and language to existing human factors work products and templates.
This paper will describe ways in which we have added considerations of patient safety into existing human factors practices. For example, an element called “patient safety implications” was added to a standard heuristic evaluation template. Although patient safety concerns are often documented during heuristic evaluations, they are sometimes overshadowed by a large volume of other usability findings that may not tie as directly to safety. The inclusion of this field prompted the HFE evaluators to think more explicitly about risk assessment and to clearly document their concerns, which provided additional support for their recommendations to the project team.
Another project focused on the “prevention of errors” heuristic and used the structure proposed by Woods and colleagues (2012) to evaluate the design of medication administration messages and recommend revisions. This proposed structure focused on concepts from error-tolerant design, whose features include considering error prevention, reduction, detection, identification, correction, resumption of normal activities, mitigation, and surveillance (Wood & Byrne, 2002). Prompts and display elements were designed in a cognitive aid to help reviewers facilitate conversations surrounding and capture concerns about latent design issues and systems aspects that may improve or impinge on error tolerance. The presentation of these findings supported funding for significant changes to error messages in the electronic health record.
Other examples will describe incorporating a graphical depiction of use generated during a task analysis and ways in which we elicited direct provider input on patient safety concerns. We will also share feedback from project stakeholders that may help tailor HFE efforts moving forward.
Though some techniques may seem insignificant at first glance, there is real value in purposefully and systematically integrating them into HFE activities. These techniques provide us with a framework and terminology to effectively communicate concerns with stakeholders in ways that will support actions to promote usability and patient safety. By sharing these experiences, we hope to enter into conversations with other HFE practitioners that may help us all strengthen our collective efforts and deliver greater value for our patients.
References
Carayon, P. (2010). Human factors in patient safety as an innovation. Applied ergonomics, 41(5), 657-665.
Carayon, P., Wetterneck, T. B., Rivera-Rodriguez, A. J., Hundt, A. S., Hoonakker, P., Holden, R., & Gurses, A. P. (2014). Human factors systems approach to healthcare quality and patient safety. Applied ergonomics, 45(1), 14-25.
Fuller, H., Arnold, T., O’Neil, M., & Wilson, D. (2023). Activities to Promote Resilience During Health Information System Transitions. Healthcare and Medical Devices, 79:191-197.
Fuller, H., Arnold, T., Maddox, K., & Adams, K. (2022). Considerations and Strategies for Operationalizing Heuristic Evaluation Work. Healthcare and Medical Devices, 51(51).
Grissinger, M. (2010). The five rights: a destination without a map. Pharmacy and Therapeutics, 35(10), 542.
International Organization for Standards (ISO) 9241-110:2006: Ergonomics of Human-System Interaction – Dialogue Principles.
ISO 9241-11. (2018). Ergonomics of human-system interaction — Part 11: US
Karsh, B. T., Holden, R. J., Alper, S. J., & Or, C. K. L. (2006). A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. BMJ Quality & Safety, 15(suppl 1), i59-i65.
McCormick, EJ, & Sanders MS. (1982). Human factors in engineering and design. McGraw-Hill Companies.
Shneiderman B, Plaisant C. (2010). Designing the user interface: Strategies for effective human-computer interaction. Pearson Education India.
Watts, B. V., Williams, L., Mills, P. D., Paull, D. E., Cully, J. A., Gilman, S. C., & Hemphill, R. R. (2018). Curriculum development and implementation of a national interprofessional fellowship in patient safety. Journal of Patient Safety, 14(3), 127-132.
Wood, S. D., & Byrne, M. (2002). A Cognitive Approach to Designing Human Error Tolerant Interfaces. In Proceedings of the Annual Meeting of the Cognitive Science Society (Vol. 24, No. 24).
Wood S, Krieg J, Murphy D. (2012). Designing Error Dialogs and User Feedback - Guidelines. VHA Office of Informatics and Analytics. [Accessed October 4, 2021].
World Health Organization. (2011). WHO multi-professional patient safety curriculum guide. Geneva: World Health Organization.
Zhang, J., Johnson, T. R., Patel, V. L., Paige, D. L., & Kubose, T. (2003). Using usability heuristics to evaluate patient safety of medical devices. Journal of biomedical informatics, 36(1-2), 23-30.
Event Type
Poster Presentation
TimeTuesday, March 264:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives