You hear about medical mistakes in the news, but you rarely hear how to fix the problem. A museum might hold some answers.
Doctors and nurses have high-stress jobs in which every second counts and there’s no room for mistakes. But to err is human, so is perfection too much to ask to keep patients safe?
Dr. John Gosbee says, "It turns out that human nature is such that that’s kind of difficult to teach.”
Dr. Gosbee is a human factors engineer who works to improve patient safety, not by making humans foolproof, but by making the high-tech world they work in user-friendly through better design.
He says, "Rather than trying to perfect them in very complex pieces of equipment, let’s make those pieces of equipment easier to use; less error-prone.”
That’s the idea behind the Hands-on Museum for Patient Safety at the Department of Veterans Affairs. Healthcare professionals take on challenges posed by familiar medical situations. Museum curator Linda Williams says visitors are often taken by surprise.
"The assumption is, I think, generally that you work with this equipment and you learn how to use these devices and for the most part, you use them well,” the registered nurse says.
“I think the surprise comes in when they discover that there are actual design issues that the devices themselves are designed by humans also, so there are problems.”
That's where the problem-solving begins.
Dr. Gosbee says, "How can we put signs on it? How can we change the color? How can we make it hard to attach the wrong things, make it more obvious you're attaching the correct things."
The goal is for medical professionals and the makers of medical equipment to trade ideas, solve problems and make it safer for patients.
The hands-on museum is based in Ann Arbor, Michigan, but the exhibits have been taken on the road. For more information, click here.
Fast Facts:One in six Americans has experienced some type of medical, drug or laboratory error.
Medical mistakes can have costly, and sometimes, deadly consequences. Drug errors alone injure 1.5 million Americans and cost our country an extra $3.5 billion annually.
In many cases, medical errors can be prevented.
The VA National Center for Patient Safety has developed an exhibit of examples of medical designs – both good and bad – to teach people involved in health care to look for flaws that may contribute to a medical error.
The exhibit also challenges those involved with health care to think of ways to improve designs and reduce risks to patients.
Patients seek medical advice to get better. Unfortunately, the process/outcome isn’t always a positive experience. In a recent survey by the Commonwealth Fund, one in six respondents said they were a victim of a medical, drug or lab test error during the past two years.
In 1999, the Institute of Medicine issued a report, To Err is Human, citing 44,000 to 98,000 deaths in hospitals each year that can be attributed to medical errors. The mistakes cost our country about $37.6 billion annually. In an updated report, the Institute finds medication errors to be the most common type of medical error, injuring at least 1.5 million people annually and costing an extra $3.5 billion for treatment.
There are many reasons medical errors occur. Sometimes two drugs will have names that look or sound alike. A drug that is meant to be diluted in an IV infusion may be directly injected into the body. Risk may increase if a health care worker is tired or feels rushed to complete treatment.
Equipment issues can also be a problem. Sometimes a medical device doesn’t work as planned. Poor designs can lead to confusion when trying to use a device, causing improper connections or a malfunction of the equipment.
Preventing Errors: Human Factors Engineering
When a medical error occurs, others are often quick to place the blame on the worker. However, sometimes other issues play a role in the risk for error. Human factors engineering is the study of how humans interact with technology, taking into account human ability, limitations, environment and system design. In the field of health care, human factors engineers acknowledge that workers are vulnerable to stress, sleep deprivation and unpredictable situations that can influence response and work flow. The goal of the engineers is to understand human limitations and make design recommendations that reduce the risk of patient harm.
An important way to study and address the problem is to look at “close calls” – situations where a potential medical error nearly occurred and was prevented. These events are usually not recorded because they don’t cause any harm to the patient. However, they can provide the basis for a better understanding of “what went wrong” and “how it could be prevented.”
At the VA National Center for Patient Safety in Ann Arbor, experts have put together several exhibits that provide examples of problems associated with medical devices. It’s called The Hands-On Museum For Patient Safety. For example, there are several Ambu Bags (pump-like balloons used to manually provide air for a patient) in the collection. One of the bags has no clear point of connection for the air mask, showing how easily a health care worker could have trouble correctly attaching the mask. Another bag turns out to be defective, highlighting the need to be prepared for unexpected equipment failure during an emergency. In another example, an infusion pump with several buttons has no clear directions for use. A health care worker who is unfamiliar with the device may not properly program the pump, leading to medication errors. Instead, detailed directions should be clearly visible on the pump. Other exhibits show examples of good designs that minimize the risk of error.
The patient safety exhibit travels around the country. Doctors, nurses, teachers, administrators and others involved in health care are able to interact with the items on display and see first-hand how equipment design can influence use. The displays help supervisors and trainers be more aware of other factors that can affect worker performance and patient safety. Exhibit managers hope the interactions will also stimulate health care workers to think about potential design flaws in the equipment they encounter every day and find ways to improve the design and reduce the risk of medical error.
The FDA has a website on its human factors program. Click here.
For general information on patient safety:AHRQ patient safety network Web site
Association of Operating Room Nurses Web site
Institute for Healthcare Improvement Web site
National Patient Safety Foundation Web site
Patient Safety Institute Web site