Designing Out Medical Error, DOME,
was a three year, EPSRC-funded, multidisciplinary project aimed at
designing safer healthcare equipment, processes and devices. The project
brought together clinicians, designers, psychologists, human factors
and business expertise to develop solutions to potential errors in and
around the hospital bed-space. By taking a systems approach to design,
the project identified causes common to a range of failures in the
highest risk processes. The project has produced a range of designs
including the CareCentre™, which is now in clinical
There are around 100,000 reports of patient safety
incidents per month to the National Reporting and Learning Service from
NHS Trusts in England and Wales. Other sources of estimated harm place
the rate of in-hospital adverse events (unintended injury or
complication) at almost 1 in 10 admissions.
ergonomics/human factors is now a constituent of safety management and
systems design in many industries, healthcare is one area in which it
doesn’t play a large role. Yet the complexity and distributed nature of
healthcare means there are extensive opportunities for human factors to
contribute to improvements. A single patient journey can cross
boundaries between the primary, secondary and tertiary healthcare
sectors, and care is often delivered by distributed teams working in
emergency situations within unfamiliar and multifunction workspaces.
Medical devices are a component of virtually all healthcare processes
from bedside lockers through to life support systems, but usability
issues are often under recognised or reported.
The objectives of the DOME study were:
develop a multidisciplinary approach to designing for patient safety
that would provide long term engagement and potential for future design
- To map, analyse and prioritise the hazards in a surgical ward.
- To develop design solutions using a systems approach and co-design methods.
took a systems approach to the design of the healthcare processes,
equipment, environment and information used in the bed-space of a
typical surgical ward. Applying this approach to such a common workspace
means that the methods and solutions will be transferable to many other
clinical specialties and settings. Rather than focusing on a particular
type of error, incident or activity, the project took a holistic view
of the activities that take place around the bedside. This approach
allowed the systems’ influences on the safety of all aspects of care to
be considered in parallel. A collaborative approach saw designers and
clinicians involved in joint observations, data collection and design
activities, and facilitated knowledge and skill transfer between
A mixed-methods approach was adopted, utilising
methods from psychology, human factors, social science, operational
management and design. This approach included observations, interviews,
surveys, shadowing, mapping of healthcare processes, Failure Modes and
Effects Analysis, risk identification and prioritisation, focus groups,
causal analysis, generation of design briefs, concept generation, brain
storming, co-design, simulation studies and clinical trials and
A work analysis was conducted based on 70 hours of
observation on five general surgery wards at three hospitals during the
day, night and weekend. The work analysis identified 14 top-level
healthcare processes around the bedside, each with numerous
sub-processes, such as:
- Hand hygiene e.g. alcohol gel, soap, water
- Vital signs monitoring e.g. blood pressure, pulse, respiratory rate
- Ward round e.g. history taking, writing notes/forms
- Medication delivery e.g dispensing medication, management of IV drips and stands.
the large number of activities observed, the processes were risk
assessed by healthcare workers, patients and visitors using subjective
rating scales. The highest risk processes were identified as hand
hygiene, vital signs monitoring, isolation of infection, medication
delivery and handover of information. A Healthcare Failure Modes and
Effects Analysis was then used to identify how each of the surgical ward
healthcare processes could fail.
Nearly 200 potential failure
modes were identified in just these five processes. Further analysis of
the top 60 failure modes identified the contributory factors. Design was
cited as a contributor to the high risk failures in all five processes.
A lack of reminders, and poor monitoring of staff performance and
feedback were also common, together with a lack of standardisation,
issues with leadership, clear team roles and responsibilities,
education, training and patient safety not being a priority.
research was then translated into a set of meaningful design briefs
which captured the research findings providing realistic boundaries for
design work and they inspired a breadth of ideas. The decision was taken
to base the briefs on the broad understanding of the failures in each
of the five processes rather than rooting them in certain, specific
failures. For instance, rather than focusing on a specific failure such
as the step “decide to wear gloves and apron”, the briefs addressed the
failures and the causes across the whole process. Also, by considering
each process simultaneously, the design work addressed potential
failures in the system of interlinked processes which make up the
typical activity around the bedside. Five interlinked briefs were
therefore formed around the processes of hand hygiene, isolation of
infection, vital signs monitoring, medication delivery and handover of
information. These briefs were validated by a process expert in each
case to ensure they captured the findings of the research.
iterative design process was followed where ideas were continuously
presented to healthcare workers and patients for critical input. One of
these, the CareCentre™, was developed primarily in response to the
isolation of infection brief, although it also addresses many of the
other briefs, demonstrating the merit of considering multiple processes
and design briefs simultaneously. Shadowing nurses trying to follow
correct protocols revealed that much time was wasted searching for
gloves and aprons which were often located far from the bedside.
observations were extended to include the use of other equipment for
common bedside processes. It was found that the medication locker was
often inaccessible (located on the wall, often with a patient
obstructing), gloves and aprons were situated away from the bedside,
there was no flat surface for reviewing or writing documents, cleaning
wipes were not within easy reach (again, located on the wall), and the
hand gel at the foot of the bed was difficult to access from the
The concept of rationalising all this equipment into a
‘one-stop-shop’ met with user approval, and through a series of feedback
sessions with front line staff, the list of contents of this all-in-one
unit was defined, as well as its position at the end of the bed.
first prototype was produced and taken to over 120 staff for review.
This featured a flat surface for writing documents, a medication locker,
hand gel, cleaning wipes, aprons and gloves, and a folder holder to
contain the patient’s charts. The concept was designed to hook over the
end of the bed. Following further iterations and user feedback, the
CareCentre™ is now in manufacture and is in clinical trials.
outputs from the study include signage for hand hygiene, a re-designed
vital signs trolley with retractable leads, a mobile phone application
for recording respiratory rate, a medication dispenser that records
missed medication, and design requirements for a handover space.
By Beverley Norris, Jonathan West & Oliver Anderson