Learning from Autopilot Problems

What can the healthcare industry learn from the risks introduced by the rise of increasingly automated airplanes?

It's all about communication

How one doctor is changing patient safety around the world by improving communication in the operating theater.

Willing to let others know you're human to improve #patientsafety?https://t.co/oCHmeUgExn #knowyourhuman pic.twitter.com/1bpSy2m91E

— Rob Hackett (@patientsafe3) December 4, 2017

Monitor Alarm are still in the ECRI Institute top 10 health technology hazards

The ECRI Institute published its 2019 top 10 health technology hazards, and physiologic monitor alarm are still on this list.

The ECRI published its top 10 patient safety concerns for 2017

The ECRI published its top 10 patient safety concerns for 2017.
Although it is not mentioned in this report, human factors tools and methods can improve most of these patient safety concerns.

Automation is identified as one of the top 10 health technology hazards for the first time

The ECRI Institute have published its Top 10 Health Technology Hazards for 2017, and Automation is identified as one of the top 10 technology hazards for the first time.

Safety improvements doesn't need to cost much

“The Dutch Reach is a practice where instead of using your near hand — usually the driver’s left hand — to open your car door, you use your far hand. Your right hand. In doing that, you automatically swivel your body. And you position your head and shoulders so you are looking directly out. First, past the rear-view mirror. And then, you are very easily able to look back and see if there are oncoming bicycles or cars or whatever.”

http://99percentinvisible.org/article/dutch-reach-clever-workaround-keep-cyclists-getting-doored/

Clinical Human Factors Group has published their Common Terms in Human Factors

Clinical Human Factors Group has published their Common Terms in Human Factors.
This is a 26 pages interactive catalog, written by Christine Ives and Steve Hillier.
The catalog brings not only the explanation but also examples for common terms.

You can find the document (pdf file) here.

Why Can’t an ICU Be More Like a Cockpit? by Keith S. Karn

Here is an interesting blog post by Keith Karn about our human factors work in the ICU.

Cars' Black Box

The circumstance that led to more than 13 deaths linked to General Motors ignition switch defect will not be discussed in this post. However I would like to highlight the important part that the so called "black box" played in the investigation of these cases. 
The interaction between a complex technology and a human operator raise the need for an external, objective, source of information that can shed some light on what exactly happen during this interaction. Our default assumption that the technology part of the system was operating as expected and that the human operator is prone for error, need a reliable source of information that will tell us what actually happen. Now we just have to make sure that the 'black box" capture all the information that we need in order to understand what happened.

What Can Happen When Operators Rely Too Much on Automation?

I already referred to the danger in relying on automation. The Asiana Airlines Boeing 777 passenger jet, that crashed while landing at San Francisco International Airport on July 2013, is a good example for what can go wrong when operators rely on automation.

In a June 24 press release said NTSB acting chairman Christopher A. Hart: "In this accident, the flight crew over-relied on automated systems without fully understanding how they interacted. Automation has made aviation safer. But even in highly automated aircraft, the human must be the boss.".

This lesson must be learned before we start implementing automation in healthcare.

Alarms in healthcare - not much has changed

The conclusions of this 2014 study - "Since 2005–2006 when the first survey was conducted, not much has changed. False alarms continue to contribute to a noisy hospital environment, and sentinel events related to alarm fatigue persist. Alarm hazards are a significant patient safety issue."

Wearable Technology - Is this the future user interface for clinicians?

Philips built proof of concept that transfer patient vital signs into Google Glass.

That's an interesting use case for wearable technology, and once the integration will be reliable this might be the future user interface for clinicians.

(image source: Philips.com)

FDA launches openFDA

The FDA launches openFDA - an open interface designed to make it easier to access large, public health datasets collected by the agency. (You can find an example of a report generated by this interface here).

While having publicly available datasets of adverse events is always a good idea, one need also to think about the known issues of under-reporting in healthcare. There are many good reasons why the healthcare system suffers from under-reporting, and when we analyse this data we always have to ask ourselves - what can we learn from the tip of the iceberg.

Switching to manual mode

When the air traffic controllers' system in southwestern United States went out on April 30, 2014, the operators at the regional center had to switched to a back-up system so they could see the planes on their screens. "Paper slips and telephones were used to relay information about planes to other control centers."

This is a good example for the human operator role in complex systems - improvising and taking control when the technology part of the system fail. This also demonstrate how important it is to maintain the operators' skills to run the system without the technology that support them during normal operation.

This lesson should be learned when we implement new technologies and automation in healthcare.

(image source: http://en.wikipedia.org/wiki/File:Air_traffic_controller_schiphol_tower.jpg)

Technology has gotten out of control

Alarms in healthcare are not a new issue, and most of the work is still ahead of us.
But what caught my eye in this NPR report is the Joint Commission's chief medical officer (Dr. McKee) quote - "technology has gotten out of control" -
Still, accordion to the Join Commission report, new requirements will be implemented as early as 2016.

Will these new instruction solve the problem?
As long as we continue to look at the technology part of the system without looking at the operator that use the technology, we will not get to a working solution. Our user has his limitations, and the amount of alarms (s)he can response to is limited. Alarm system that will not take this into consideration will always leave the system below its optimal point.

photo source - NPR