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Poor Interface Design and Lack of Usability Testing Facilitate Medical Error

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Background: A fictional scenario based on a compilation of several real events describes seven medical errors that at first appear to be caused by the paramedics and nurses involved.

Human Factors Engineering (HFE) Analysis: An emergency medical services paramedic attempted to use a debrillator on a 67-year-old man with ventricular tachycardia. Yet nothing happened. The defibrillator displayed an indication that it was in synchronized mode but provided no feedback to tell the user that it was not prepared to shock because of low QRS amplitude.

Usability Testing: A hands-on approach to discovering the difficulties and potential for error that people encounter when trying to use a product, usability testing can help to create medical devices and systems that are not only more "user friendly" and efficient—but safer.

Recommendations: Recommendations are presented to enable health care leaders to apply human factors considerations in their product evaluation and purchasing decisions. Medical device manufacturers should involve human factors engineers in the design process from the outset and should perform usability testing. Health care organizations should expect an optimized and tested user interface in the medical devices they purchase.

Summary: Many adverse events in medicine are the result of poor interface design rather than human error. The HFE concepts of usability and standardization are critical to patient safety.

Document Type: Research Article

Publication date: October 1, 2004

More about this publication?
  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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