From Proceedings of the Human Factors and Ergonomics Society 42nd Annual Meeting, October 5-9, 1998
HUMAN ERROR IN PATIENT-CONTROLLED ANALGESIA: INCIDENT REPORTS AND EXPERIMENTAL EVALUATION
Human error is often cited as the most common cause of medical device mishaps. The role that a poorly designed user interface plays in precipitating these errors is infrequently acknowledged. This study focused on the Abbott PCA Infuser, a commonly used medical device. A review of FDA incident reports showed that human error is responsible for 68% of fatalities and serious injuries associated with the Abbott PCA. We sought to demonstrate that the incidence of human error can be significantly reduced through a human factors approach to interface design. A redesigned interface was developed, then empirically evaluated with a group of recovery room nurses, experienced PCA users. The results of the evaluations showed a 55% reduction in errors, an 18% improvement in performance time, a 14% reduction in mental workload, and a strong preference by nurses for the redesigned interface. These findings demonstrate that quantifiable improvements in equipment safety and efficiency can be achieved by adopting a human factors approach to interface design.
As many as 100,000 deaths or serious injuries occur each year in the U.S. as a result of medical accidents (Van Cott, 1993). It is believed that a significant number are related to the misuse of medical devices (Burlington, 1995; Carstenson, 1995). Human error is often cited as the most common cause of medical device mishaps. However, what is less frequently acknowledged is the notion that a poorly designed human-machine interface predisposes medical device operation to human error (Bogner, 1994a; Bogner 1994b; Hyman, 1994; Cooper et al., 1978). The hypothesis explored in this study is that human factors engineering can significantly improve the safety, efficiency, and ease o
Contact: Lois Smith
Human Factors and Ergonomics Society