Human Factors in Healthcare Blog

In no particular order, here is what I learned this summer:

1. All cars sold to haul kids on vacation trips should have “glass wall” options like taxis to close off the back seat noise and shrapnel
2. If someone says they are car sick, it is better to stop and spend 5 minutes for a short walk than to clean vomit for 15 minutes
3. GPS systems can be wrong…really, really wrong:  “turn left onto the (non-existent) ferry”
4. Seemingly small wayfinding and other design flaws in hospitals can grow large when your friend or brother are sick
5. Medical residents are getting more and more savvy about patient safety (this is a good thing)
6. Medical residents are impatient with progress in patient safety (this is a great thing)
7. You can say you are going to write blog posts every week, then life happens

For those (still) reading my posts, I am going to upgrade the system to make sure you get announcements of my new posts.  For those about to read my posts, I am going to improve my marketing and networking to inspire me to continue my posts more regularly.

Last week my dad found and read the print-out of my first 12 Blog postings.  He was very interested, and we talked about the useful nature of the Blog.  He thought it could have a wide audience and most postings were readable.  I had given him the print-out weeks ago, but until recently it was lost in a pile of other papers and items that are stacked 3 feet high near his TV chair.  He does not have a computer – so he had to read the paper version.  He is not computer-phobic, since he actually had used computers in his high-school class since the early 1970s (yes, 1970s).

My dad has been an indirect and direct inspiration to my work.  In 1998, I wrote an editorial to British Medical Journal about human factors engineering aspects of physician communication.  I wanted to humanize the editorial (critique) for this popular medical journal, but also push the concepts and methods of the underappreciated HFE.  So, I told the story of a miscommunication of a echocardiogram (ultrasound of the heart).

In 1997, a nurse had told my dad that the “Echo” report said that he had aortic stenosis, and needed to be seen by a cardiologist.  He told me later, and I was stunned because symptomatic aortic stenosis has a very poor outlook.  I happened to be traveling to Northern Wisconsin that next week and was anxious to learn more about any further testing and the plan (e.g., surgery?).  When I arrived and talked to my dad, he told me the nurse called back and said, “never mind, we got the report wrong, you only have minor changes of atherosclerosis!”  This is a fairly common finding for this age, and often not a big deal.  Since the mistake went in the good direction for my dad, we all laughed about it.

Years later, I was to find that there is a whole host of look-alike and sound-alike terms that get messed up during dictation, transcription, verbally communicating, etc.  Medication names are the most infamous.  In 1990, several journals described fatal confusion between lasix and losec.  This resulted in the drug name of losec changing to prilosec.  ISMP, FDA, and other medication safety organizations have devoted much time and energy to prevent as much of this as possible.

But most safety people find out quickly that we humans do not really “read” in the same manner as a computer scans a document.  We do not synthesize stuff in our head the way a computer program does.  Humans are great at grabbing fragments of the familiar, making a best guess, and acting quickly.  Star Trek the Next Generation and other SciFi shows have used our unique power of good guessing in their ”man wins out over cyborg” episodes.

But some “tricky situations” require us to switch from using inference and hunches and go to a more step-by-step approach.  But the problem is realizing when we are in these “tricky situations”.  How do we know when to slow down.  Worse yet, if they are REALLY tricky, like watching a magic show, our step-by-step approach will still fail us.  Magicians Penn and Teller have actually helped write and present at professional conferences about some of this linkage between magic and cognitive science.

The goal of human factors engineering is to find out where we have accidentally added “trickiness” to our devices or systems.  And we really want to find out if we have made our design so tricky that a magician would be proud.