“Medical error is the 5th or 6th leading cause of death in the US”, is the opening line of human factors professional Ken Catchpole in his presentation to an audience in Santa Monica (see below for the video). His talk is an introduction to human error in healthcare and some of the situations that make it more likely that medical staff will make mistakes.
Ken emphasises that errors are not necessarily made by poor practitioners but can be made by anyone, if there is a sequence of events which makes it much more likely the error will occur. What he finds so difficult to understand is the fact that the same mistakes keep happening in healthcare, whereas in industries such as aviation and nuclear this is not the case. This is because they use human factors expertise to analyse the cause of accidents and then use this knowledge to design systems to support people’s behaviour, in other words they apply ergonomics principles to design.
Among his many examples of issues with equipment design are two different infusion pumps where the number pad of one had 7, 8 and 9 buttons along the top row, with the second one having numbers 1, 2 and 3 in the same position, “so we are making people make mistakes” he says. Then, there is an example of an on/off button on an anaesthetic machine positioned next to the function button. “Sometimes, this is not rocket science,” he points out. An audience participation exercise reveals how the brain can have blind spots and how understanding how people’s brain works is important when it comes to designing out errors.
Hospital hierarchy in the operating theatre is another element that has been identified as leading to accidents because it is difficult for a less senior or experienced member of a surgical team to challenge the actions of the surgeon. Surgeons are trained to take control, Ken points out, but in reality they are not because there are so many other factors. A way around this would be team briefings before operations as a way of getting everyone on board with what was happening.
Ken talks about the transfer of experience from other fields. He was involved in the project where lessons were learnt from how the Ferrari pit stop team carried out refuelling and tyre checking which they did incredibly reliably during a race. The way they organised tasks and put in checks was adapted for use in a hospital setting where very sick babies were being transferred from surgery to intensive care. This approach is now being used elsewhere across the world.
Another great innovation is the creation of a simple checklist – the WHO Surgical Safety Checklist, used by doctors before they carry out an operation. The challenge for the future is to have a learning environment and with technology and treatments becoming more complex, designing safer systems is now even more important.
Ken’s talk was recorded as an independent TEDx talk in Santa Monica on 17 May 2012.
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