Hiding In Plain Sight: A Lesson in Human Factors Engineering

Dr. John Gosbee was our featured guest speaker this past Monday at our November Open School meeting. John is a Human Factors Engineering (HFE) and Healthcare Specialist who lectures frequently in the UM community for students and healthcare professionals and also has his own HFE healthcare consulting company with his wife. His interactive talk was an engaging introduction to a field very relevant to healthcare improvement. John gave us a brief history of HFE, including its birth as early as 1950 in the aviation field. As with the LEAN and other automotive engineering philosophies we have to wonder why it has taken so long for this insight to reach healthcare?

John’s talk challenged us to look at the poorly designed features ubiquitous in our daily lives, literally “hiding in plain sight”. I deal with poorly designed features everyday without thinking too much about them: from the frustratingly enigmatic knobs on my own stove that confuse me every time I try fry an egg, to features of my car that keep me guessing each time I attempt to use them, like how I usually pop open my trunk and gas tank at least 5 times when I attempt to open the hood of my car (even Toyota isn’t perfect!)

Although initially amusing, as John next discussed the context of healthcare, these seemingly idiosyncratic details quickly became terrifying. For instance, the design features of many IV medications and solutions commonly lead to fatal errors by nursing staff or pharmacists who misread the practically identical packages/labels.

The first exercise is pictured below- students were told to hold their breath and were handed epipens (fake ones without needles) and we were challenged to determine how to administer the drug before letting out our breath. Nearly six students were required to attempt what should be a simple task in light of the pressure of an emergency situation when an individual is going into anaphylactic shock! Personally, I misread the overwhelmingly detailed instructions and would have injected myself with epinephrine had it been a real needle...

The exercise reinforced the point that in healthcare, the more small things that build up requiring workarounds due to impractical design, the less we become able to compensate. Catastrophes result in the form of medical errors. While there are of course lessons to be learned by the engineers who design programs and tools used in healthcare to be user friendly and simple, there is a great deal of value for healthcare professionals to learn to spot these hazards. Developing an acute awareness of the design of tools utilized in the healthcare industry and an intentional mindfulness that workarounds are inefficient may alleviate further complications.

Apparently it's quite rare for a hospital or health system to employ an individual with the role of "human factors engineer" to watch out for threats posed by problematic design features. Therefore, knowing that small adjustments can lead to large, statistically significant improvements it seems crucial that we, as healthcare professionals, attempt to adopt similar mindsets.

As John explained, poor designs can be reported--for instance, the example of the insulin "pen" that he presented was one that was reported to the FDA because the numbers were reverseable depending on how the user held the pen. If US regulatory agencies receive feedback about patient safety threats it is feasible that they will be amended-at least moreso than if never reported! Relevant stakeholders are not limited to frontline caregivers; pharmacy, billing, purchasing and nursing departments all have something to gain by maintaining a critical eye to the design features of the electronic ordering systems, medical devices and other tools commonly used.

That's continuous quality improvement at its best.