Feature

When the aviation and space operations industries sought to enhance safety, they turned to human factors psychologists to design systems with the user in mind. By simply applying what they know about human behavior, the psychologists developed safer operating procedures and instrumentation that was easier to use.

The health-care field can learn a few lessons about reducing medical errors by looking at the work psychologists have done in that field, said APA member David Woods, PhD, at a September federal hearing on patient safety in Washington, D.C.

At the first National Summit on Medical Errors and Patient Safety Research, Woods urged policy-makers to consider human performance when conducting safety research. A discipline that seeks to optimize the relationship between technology and people, human factors can be used to "help you forecast challenges to safety" because such factors offer insights into how people will adapt to using certain systems, Woods explained.

The summit was sponsored by the Quality Interagency Coordination (QuIC) Task Force, set up in 1998 by President Clinton to bring together activities aimed at improving health-care quality.

The summit's goal was to review the information needs of people involved in the process of reducing medical errors and set a research agenda to fill those needs. A report issued by the Institute of Medicine last year, entitled "To Err is Human," found that medical errors made by health-care personnel claim the lives of 44,000 to 98,000 people every year in hospitals. The cost of such errors: $29 billion a year.

According to the QuIC report, most errors result from system failures, not from people's fault. Speaking on behalf of the Human Factors and Ergonomics Society as its past president, Woods--one of various panelists involved in research, practice, patient and policy-making--said that future research on improving patient safety must consider human factors involved in complex medical systems.

"Human error in medicine, and the adverse events that may follow, are problems of psychology and engineering, not of medicine," said Woods. "Where you are puzzled by erratic people, we see common patterns in problem-solving and cooperative work."

A systematic approach to reducing medical errors offers the best chance of reducing wrong site surgeries, delaying diagnosis and making other mistakes in hospitals as well as other health-care settings, Wood said.

"Research programs," he urged the panel, "should be built from the beginning as a substantive partnership between human performance specialists and health-care specialties."

Human factors and patient safety success stories abound, Woods said in testimony submitted to the panel. Experts from the Georgia Institute of Technology, for instance, found out that many people using blood-glucose monitors at home were using them improperly. Researchers looked at the monitors' design as well as at the instructional manual that came along with the device. It turns out, that the "three-step" blood glucose monitor actually required users to conduct 52 substeps, leaving little doubt as to why patients made mistakes. Researchers suggested a better design of the device and correct use of the meter improved dramatically.

Patient care can also be improved with more user-friendly computer interface systems.

For example, a team of experts recently designed a computer system that relied on graphics rather than text to monitor the daily care of patients. Using the system, nurses no longer had to type in orders for medication and lab tests--thus making fewer errors in dosages and recording of patients' names.

In closing, Woods told the panel that the "enemy of safety is complexity and that the calls for "more use of integrated computerized information systems to reduce error could introduce new and predictable forms of error unless there is a significant investment in user-center design."

To help the health-care industry improve patient safety, research needs to search out the sources of complexity, understand how people, teams and organizations deal with complexity and come up with better ways to help people cope with complexities to reduce errors.



Marcela J. Kogan is a freelance writer in Chevy Chase, Md.