(REILING, 2006)

The formal study of error and design dates from the Second World War. Studies of aviation accidents revealed that some were caused by pilots incorrectly operating very similar or confusing controls. In a classic early example, nearly identical cockpit controls for retracting the flaps and retracting the landing gear were placed alongside each other in some aircraft, causing pilots to retract the landing gear after they had landed, with disastrous results. Engineers began to realize that they had to take the psychological characteristics of human beings into account as well as the technical issues. This gave rise to the discipline of ergonomics, sometimes called ‘human factors’:

Ergonomics (or human factors) is the scientific discipline concerned with the understanding of the interactions between humans and the other elements of a system, and the profession that applies theory, principles and data and methods to design in order to optimise human well-being and overall system performance.
(CARAYON, 2007)

For me, as a (biased) psychologist, much of ergonomics is psychology under another name, as it concerns issues such as perception, cognition, human performance, teamwork and organizations. Ergonomics however, has a particular focus on the interactions between human beings, technology and organizations and a strong emphasis on practical applications. Ergonomics was traditionally focused on the design of equipment and furniture (e.g. appropriate chairs and lighting), which is indeed an important component, but the definition makes clear that the cognitive and wider organizational and systemic perspectives are also included in the overall approach. This leads to an extraordinary range of activities and a huge amount of confusing terminology: human machine interfaces (hardware ergonomics), human computer interaction (cognitive ergonomics), organizational issues (macroergonomics) and so on.

Design for safer healthcare

Designers of healthcare equipment have to consider many different requirements and perspectives, but safety is often to the fore. For instance, a number of safety features that have been designed into anaesthetic gas systems. Lines for oxygen and nitrous oxide attach to a special port set in the wall or ceiling. These lines are colour coded (in Britain, oxygen is white, nitrous oxide is blue) and each pipe has a specific connector and collar that makes it impossible to attach an oxygen pipe to a nitrous oxide port and vice versa. Spare oxygen and nitrous oxide cylinders also have the same connectors and also a ‘Pin Index System’, which ensures that only oxygen cylinders can be fitted to the space designed for oxygen. These design features make it more or less impossible to miss-connect gas pipes.

Just as medicine has increasingly adopted an evidence based approach to treatment, designers and healthcare professionals have embraced evidence based design and there is now a substantial and growing literature. This has been recently reviewed and very effectively summarized by Roger Ulrich and colleagues at the Centre for Health Design, University of Georgia, and we will draw extensively on their review in this chapter. The involvement of designers and architects who appreciate the healthcare context, and the potential impact of design on safety and quality, has been given increased impetus by the fact that the United States, and a number of other countries, are engaged in a massive programme of hospital building. Many 1970s buildings have become unsuited to modern healthcare and building a new hospital is often more cost-effective than upgrading (Ulrich et al., 2008). However, let us begin with something rather more modest but equally critical – the design of labels and syringes.

Designing out medication error

Reducing medication error requires a multi-faceted approach involving computerized systems, simplification and standardization of clinical processes, education and training and wider cultural and organizational change. However, the design of labelling and packaging can be an important contributor to error and, by the same token, an important part of the solution. For instance, look-alike/sound-alike drug names are a serious problem in healthcare, accounting for 29% of medication dispensing errors. Confusion of drug names is a problem in about 20% of medication errors overall. Illegible handwriting, incomplete knowledge of drug names, new products and similarities in packaging and labelling, act as contributing factors to this problem.

Medication errors involving look-alike/sound-alike drug names can cause serious patient harm. For instance, a number of errors have been reported and published on the confusion between Lamisil^® and Lamictal^®. Reading these two names quickly, one can easily see how they could be confused, but re-design of the labels to highlight the differences rather than the similarities makes them markedly distinct (Figure 12.1).

Figure 12.1 Distinguishing drug names through good design (Reproduced with permission of National Patient Safety Agency: www.npsa.nhs.uk).

The UK National Patient Safety Agency has drawn together a group of experts from healthcare and the pharmaceutical industry to draw up guidelines and to illustrate approaches to design that can reduce errors. As with any design for safety projects, they first identified the most common labelling related medication errors and then identified potential solutions or at least methods of reducing the likelihood of such errors (Boxes 12.2 and 12.3).

Some of these seem so simple as to be obvious, but all of them are relevant. Many medicines have packaging which is difficult to read, hard to open, with confusing methods of presenting information. Simple changes make crucial information stand out. For instance, anaesthetists in the United States, Canada, Australia and New Zealand developed a standardized colour coding for labels for the syringes of medications drawn up in the operating theatre; however, this has apparently not been universally taken up by the manufacturers (Berman, 2004). It is also important to realize that recommendations, while they take account of human psychology, are not absolute. We might all, for instance, agree that colour coding will be helpful in distinguishing different classes of drugs or different routes of administration, but unless there is co-ordination between manufacturers or an international standard, the potential for confusion remains. In addition, there are few studies as yet, either simulated or in clinical conditions, of the impact of changing packaging on error rates.

Although the attention given to these issues is very welcome, the pharmaceutical industry has not as yet put its weight behind patient safety, although

there are some notable exceptions. For instance, in ophthalmology, where many patients naturally have poor vision, manufacturers have been using brightly coloured bottle tops to help patients identify eye drops and, because they often cannot read the labels, to prevent substitution errors between drugs. Similarly, after numerous problems and some deaths due to potassium chloride (where concentrated potassium chloride would be mistakenly injected instead of a weak sodium chloride solution), vials of potassium chloride in the United States now have a black top and are clearly labelled ‘must be diluted’ (Berman, 2004).

Re-designing the resuscitation trolley

If a patient’s heart or breathing stops in hospital, an emergency ‘crash’ team of doctors and nurses is called to resuscitate the patient. Many studies have examined the success of resuscitation and have generally found that only 16 to 20% of patients survive the arrest to be discharged from hospital (Kalbag et al., 2006; Sandroni et al., 2007). The crash team uses a large array of medicines and medical devices such as a defibrillator, which are stored on a ‘crash trolley’. This is permanently stocked and wheeled to the patient’s side.

The first crash trolleys were introduced into hospital wards in the 1940s. Since cardiopulmonary resuscitation (CPR) was first described, there have been constant revisions and an evolution of the resuscitation process. This has not been echoed in the design of resuscitation trolleys, which are little more than modified tool trolleys. Though they fulfil the basic function of being mobile and providing space for equipment, they hinder rather than help the resuscitation team battling to save the patient in the few minutes they have available. At this most critical time, drawers often don’t open properly, the wrong equipment is selected in error, the equipment may not be stored correctly and it is difficult for more than one person to access the trolley at any one time.

Resuscitation is also often hampered by poorly stocked trolleys being taken to the scene. Existing trolleys have all the equipment hidden away in drawers, often locked with a tamper seal. A daily check should be performed, which (if done at all) is done during a quiet time, often on a night shift. The procedure consists of removing equipment, item by item, and checking it against a list. This can be done in 20 minutes if the checker is experienced, but may take up to an hour, all of which takes time away from direct patient care.

In this project designers were teamed with clinicians, academics and psychologists, and were immersed in the clinical environment from the beginning. The team examined Advanced Life Support guidelines, attended courses on resuscitation, watched videos of resuscitations and experienced clinicians and resuscitation officers were interviewed and observed in numerous scenarios. This helped to build a detailed picture of the processes and associated errors throughout the resuscitation process. A Failure Mode and Effects Analysis (FMEA) was carried out to map what errors occurred, and at what point. Successive design ideas were developed and presented to clinical staff in a series of iterations and refinements. The clinicians were invited to talk through the benefits and drawbacks of each one, combining and rejecting functions as they saw fit. This led to a design prototype with the following features:

• The new trolley design has an open layout, similar to a shadow board in a workshop. This means that all the equipment can be seen at a glance, making access much easier and facilitating stock checks.
  
• The trolley can be split into three sections: one unit for managing the airway, one unit for drugs and intravenous care, and the final unit for miscellaneous items. This aids access and also helps to define team roles in an emergency.
  
• A Radio Frequency Identification (RFID) antenna was placed in the central unit to detect when items are removed, flashing up a warning on a touch screen when the stock is incomplete. This also facilitates the restocking process as the technology can display exactly what is missing, and the expiry date.

Figure 12.2 A standard resuscitation trolley.

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