Monday, July 7, 2014

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.

Sunday, June 22, 2014

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."

Monday, June 16, 2014

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:

Sunday, June 8, 2014

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.

Sunday, May 25, 2014

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:

Monday, March 24, 2014

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

Thursday, February 13, 2014

Patient safety at patients' hands (Part 2)

The National Patient Safety Foundation urges public to "Navigate Your Health…Safely".
From the PR message: "Providing safe patient care can best be achieved when patients are key members of the team and are encouraged to take an active role in their care."

Tuesday, February 4, 2014

Patient safety at patients' hands

A new campaign at Jewish General Hospital (Montreal, Quebec, Canada) encourage patients and their family members to be alert and ask questions when receiving medication treatments.

Photograph by: Marie-France Coallier , The Gazette

Thursday, January 2, 2014

Is there a business model for patient safety?

The report that Patient Safety Technologies was bought for $120 mln. might be a sign that the business market believe that there is a business model for patient safety. Patient Safety Technologies claim to fame is a $10 per surgery bar coding technology (THE SURGICOUNT SAFETY-SPONGE® SYSTEM) that aims to reduce the incidence of sponges left in the body after surgery.

(Image source Stryker website)