EBME Forums Forums Free discussion Out of Hours Technology Medical Device Usability and Human Error

Let's get this one back into play!

After all, we could come up with the specs for the "perfect designs" right here, could we not?

How about we start with:-

1) Syringe Pump
2) Volumetric Infusion Pump
3) Defibrillator

For all I know (and I believe that I may), the "perfect" examples of each could already exist!

Would anyone like to weigh in with their own candidates (or, indeed, their own design specs)?

It would be easier to redesign the human, especially the 'brain' part

Whilst there will always be equipment users from the shallow end of the gene pool, don't forget, Neil, that our nurses all have degrees now.

Quote "Neil, that our nurses all have degrees now"

Thats usually a few degrees above room temepature.....

Simple mistakes are made by people right across the board from cleaners to surgeons... We all make mistakes and so I think it's a bit of an easy option to blame the users. There are different sorts of errors that people make and 'slip errors' are even made by people regardless of their expertise.

We need to move away from simple models of blaming users because systems/tools/devices/procedures can be better designed. If there is an error/incident I think people follow this train of thought:
- was the device working as the instructions suggest?
- if not, then manufacturing fault.
- if yes, then user error: blame, discipline, train, train, train.

This is a great video, inspired by an accident, which has an alternative view. It proposes bringing a better learning and safety culture into healthcare and uses the aviation industry as a good role model:
http://video.google.com/videoplay?docid=-6738698910009425483#

As a rule, we don't apportion blame. We just pick up the pieces.

The trouble is, though ... that the users like to blame the equipment when someone has "slipped up", and then (if possible, or even by association) us.

Physical design does play a part in user errors in my opinion but I find that with increasingly sophisticated medical equipment being introduced, software design plays a bigger role in user related errors.

Syringe pump = Protected arm, mains cable locked in place, large clear display (with drug being used and mL/H or equiv), On/Off button, occlusion change button, rate change button and start/stop infusion.
It forces the nurse to do a purge (therefore eliminating air in line and backlash).
It is quick to start.
It is water/fluid proof.
It has no stupid fiddley bits that will break off or not get cleaned.
It is light.
It has an alarm that makes them do something with it.

On our side= Software that works when you have to calibrate.
Four screws max.
Cheap parts.
Modular mechanism for quick repair. (but with all components available for repair)
Test equipment at a reasonable price.


Will get on to the others after I finish this pump in front of me.

Billy

Had a play with a Niki T34 syringe driver today (the one that seems to be taking over from the MS16/26A in this part of the world). Very nice I have to say. Simple user interface, I could drive it without reference to manuals or any such nonsense . Preprogrammed to a drug protocol (hospital/clinical area specific) and works in a similar way to all other pumps (you know, mls/hr unlike the MS series).

Have not seen the programming tool but others of my team have and the reports are good.

A step forward in patient safety by the looks of things.

bcarlise
good list on the needs of a pump but I would not agree with the user being able to change the occlusion this should be set at an upper limit that is safe .If the pump alarms occlusion there is a reason and the user should not be able to alter the limit so as to just silence the alarm