The prevalence of medical errors and the difficulty of using medical devices are such common complaints among health care providers and patients that I won’t bore you with the usual statistics. I think we all know these are grand challenges for the HF/E profession. But a look back at a 2012 article in User Experience magazine by Shannon Clark and Ed Israelski reminded me of how little progress we seem to be making. They share a few famous health care human factors stories that we see in the mass media whenever there is a major incident, but then fade into the background when the general public’s limited attention span runs its course. I was reminded of this when reviewing the program of the 2015 Human Factors in Health Care conference.
Perhaps you have heard stories of a doctor operating on or amputating the wrong limb. Even though this is an age-old problem, some medical devices cause the user to confuse the sides of the body, consequently leading to recalls of the devices. Just last year, the U.S. Food and Drug Administration (FDA) recalled a software system because the interface led doctors to confuse the left and right sides of the brain when evaluating patients. Imagine the consequences of this design flaw during brain surgery!
The most famous one is when patients or nurses write in marker on their bodies to remind surgeons of where to cut. These errors are not inattention by the surgeon; it is that many of the electronic devices they use make it hard to resolve which side is being displayed. We have symmetrical bodies and our right sides look an awful lot like our left sides. A big splotch of marker ink might be the only salient difference.
Another famous failure that they review is the alarm fatigue commonly experienced by teams in the operating room or the emergency room. The medical team either needs to filter their attention through an incessant barrage of auditory and visual warnings or turn them off and risk missing something important.
Now that we are developing health care solutions as smartphone apps, another famous problem is going to get even worse. Medical device displays are notorious for visibility issues. Either the user can’t see the units, the decimal point, the mode, or any number of important pieces of information. Now that we are migrating these apps to smart watches or other wearable devices with even smaller displays, this challenge will only get worse. Moreover, app designers are often teams of just a few developers, none of whom have human factors expertise.
OK, so I know I have not told you anything you don’t already know and have not heard about dozens of times. But that should make you stop and think. If we have known about these problems for decades now, why are they still so prevalent?
Image Credit: Thirteen Of Clubs