Fully autonomous systems and fallback to human control

When you design your fully autonomous systems it is important to have a good plan for how the system will fallback to human control when needed. See what happened to this driverless Waymo.

Photo from Wikimedia

human error vs. design error

Yet another example of a manufacturer that points to human error to justify design errors.
"How Boeing’s Responsibility in a Deadly Crash ‘Got Buried’" from The New York Times.

Credit: commons.wikimedia.org

The Value of Double checking Medications

A 2019 systematic review by Dr Alain K Koyama and colleagues that was published at the BMJ Quality and Safety reviles that there is insufficient evidence that double versus single checking of medication administration reduce harm.

Standardization assist in shortening response time during emergencies

There is one thing that always assist in shortening response time during emergencies - standardization. Here is how international standardization of in-hospital-emergency-number can help. 

Google Maps Leads About 100 Drivers Into A 'Muddy Mess' In Colorado

Many of us use car navigation systems these days, and we developed some trust working with these systems over time.
Here is what can happen when we have too much trust - Google Maps Leads About 100 Drivers Into A 'Muddy Mess' In Colorado.
Now imagine how this type of incident would develop in the world of automation in healthcare.

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.