Improving safety in medical devices and systems

Proceedings - 2013 IEEE International Conference on Healthcare Informatics, ICHI 2013

Volumn , Issue , 2013, Pages 1-13

  Thimbleby, Harold ^a  

^a SWANSEA UNIVERSITY   (United Kingdom)

Author keywords

Design; HIT (Health IT); Safety; Usability

Indexed keywords

DESIGN SAFETY; DEVICE SAFETIES; ELECTRONIC PATIENT RECORD; HEALTH IT; HEALTHCARE TECHNOLOGY; MEDICAL DEVICES; SCORING SYSTEMS; USABILITY;

ACCIDENT PREVENTION; CURRICULA; DESIGN; ERRORS; INFORMATION SCIENCE; MANUFACTURE;

BIOMEDICAL EQUIPMENT;

EID: 84891758290     PISSN: None     EISSN: None     Source Type: Conference Proceeding    
DOI: 10.1109/ICHI.2013.91     Document Type: Conference Paper

References (50)

1. C. Vincent, G. Neale, and M. Woloshynowych, "Adverse events in british hospitals: Preliminary retrospective record review," British Medical Journal, vol. 322, pp. 517-519, 2001.
2. T. Lesar, L. Briceland, and D. S. Stein, "Factors related to errors in medication prescribing," Journal American Medical Association, vol. 277, pp. 312-317, 1997.
3. D. C. Classen, R. Resar, F. Griffin, F. Federico, T. Frankel, N. Kimmel, J. C. Whittington, A. Frankel, A. Seger, and B. C. James, "'global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured," Health Affairs, vol. 30, no. 4, pp. 581-589, 2011.
4. C. Vincent, P. Aylin, B. D. Franklin, S. Iskander, A. Jacklin, and K. Moorthy, "Is health care getting safer?" British Medical Journal, vol. 337, pp. 1205-1207, 2008.
5. L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, To Err Is Human: Building a Safer Health System. National Academies Press, 2000.
6. P. Aspden, J. Wolcott, J. L. Bootman, and L. R. Cronenwett, Preventing Medication Errors. National Academies Press, 2007.
7. Y. Y. Han, J. A. Carcillo, S. T. Venkataraman, R. S. Clark, R. S. Watson, T. C. Nguyen, H. Bayir, and R. A. Orr, "Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system," Pediatrics, vol. 116, pp. 1506-1512, 2005.
8. Institute of Medicine, Health IT and Patient Safety. National Academies Press, 2011.
9. D. Goldhill, Catastrophic Care: How American Health Care Killed My Father-And How We Can Fix it. Knopf, 2013.
10. C. Vincent, Patient Safety. Churchill Livingstone, Elsevier, 2006.
11. B. Goldacre, Bad Pharma: How drug companies mislead doctors and harm patients. Fourth Estate, 2012.
12. A. Cauchi, P. Curzon, A. Gimblett, P. Masci, and H. Thimbleby, "Safer "5-key" number entry user interfaces using differential formal analysis," in Proceedings BCS Conference on HCI, vol. XXVI. Oxford University Press, 2012, pp. 29-38.
13. P. Oladimeji, H. Thimbleby, and A. Cox, "Number entry interfaces and their effects on errors and number perception," in Proceedings IFIP Conference on Human-Computer Interaction, Interact 2011, vol. IV, 2011, pp. 178-185.
14. H. Thimbleby and P. Cairns, "Reducing number entry errors: Solving a widespread, serious problem," Journal Royal Society Interface, vol. 7, no. 51, pp. 1429-1439, 2010.
15. J. Reason, Human Error. Cambridge University Press, 1990.
16. A. M. Johnston, Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006. Scottish Executive, 2006.
17. K. A. Olsen, "The $100,000 keying error," IEEE Computer, vol. 41, no. 4, pp. 108-106, 2008.
18. P. Lee, H. Thimbleby, and F. Thompson, "Analysis of infusion pump error logs and their significance for healthcare," British Journal of Nursing, vol. 21, no. 8, pp. S12-S22, 2012.
19. H. Thimbleby, "Interaction walkthrough: Evaluation of safety critical interactive systems," in Proceedings The XIII International Workshop on Design, Specification and Verification of Interactive Systems-DSVIS 2006, vol. 4323. Springer Verlag, 2007, pp. 52-66.
20. -, "Ignorance of interaction programming is killing people," ACM Interactions, pp. 52-57, September+October, 2008.
21. -, "Calculators are needlessly bad," International Journal of Human-Computer Studies, vol. 52, no. 6, pp. 1031-1069, 2000.
22. Abbott Laboratories, LifeCare 4100 PCA Plus II Infuser, Rev. 10/91.
23. A. W. Wu, "Medical error: The second victim," British Medical Journal, vol. 320, 2000.
24. Various authors, I wish we were less patient; &To Err is Human: Medical Errors and the Consequences for Nurses, runningahospital.blogspot.co.uk/ 2011/05/i-wish-we-were-lesspatient. html; josephineensign.wordpress.com/2011/04/ 24/to-err-is-human-medicalerrors-And-The-consequences-for-nurses, accessed 2013.
25. Institute for Safe Medication Practices, ISMP, Fluorouracil Incident Root Cause Analysis, 2007. [Online]. Available: www.ismp-canada.org
26. Medicines and Healthcare products Regulatory Agency, MHRA, Medical Device Alert, MDA/2013/004, 2013.
27. Hospira, System Operating Manual Plum A+, 2005.
28. Zimed, AD Syringe Driver, www.zimed.cncpt.co.uk/product/ad-syringe- driver, visited 2013.
29. Federal Drug Administration, US FDA, Hospira Symbiq Infusion System Touchscreen: Class 1 Recall, www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHumanMedicalProducts/ucm326080.htm, 2012.
30. Human Factors and Ergonomics Society, Two Medical Devices Win HFES Product Design Technical Group's User-Centered Product Design Award, www.hfes.org/web/DetailNews.aspx?Id=116 (2006), visited 2013.
31. S. Syed, J. E. Paul, M. Hueftlein, M. Kampf, and R. F. McLean, "Morphine overdose from error propagation on an acute pain service," Canadian Journal of Anesthesia, vol. 53, no. 6, pp. 586-590, 2006.
32. H. Thimbleby, "Think! interactive systems need safety locks," Journal of Computing and Information Technology, vol. 18, no. 4, pp. 349-360, 2010.
33. D. Kahneman, Thinking, Fast and Slow. Penguin, 2012.
34. D. A. Norman, "Design rules based on analyses of human error," Commun. ACM, vol. 26, no. 4, pp. 254-258, Apr. 1983.
35. -, The Design of Everyday Things. Basic Books, revised edition, 2002.
36. J. Nielsen, Usability Engineering. Academic Press, 1993.
37. John Hopkins University, Infusion Pump Workshop 2012: A Systems Engineering Approach for Human Factors Solutions, 2012.
38. Institute for Safe Medication Practices, ISMP, List of Error-Prone Abbreviations, Symbols and Dose Designations, 2013.
39. R. Koppel and S. Gordon, Eds., First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety. Cornell University Press, 2012.
40. B.-T. Karsh, M. B. Weinger, P. A. Abbott, and R. L. Wears, "Health information technology: Fallacies and sober realities," Journal of the American Medical Information Association, vol. 17, no. 6, pp. 617-623, 2010.
41. E. W. Dijkstra, "The end of computing science?" Communications of the ACM, vol. 44, no. 3, p. 92, Mar. 2001. [Online]. Available: http://doi.acm.org/10.1145/365181.365217
42. H. Thimbleby, "Heedless programming: Ignoring detectable error is a widespread hazard," Software-Practice &Experience, vol. 42, no. 11, pp. 1393-1407, 2012.
43. J. Kruger and D. Dunning, "Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self-Assessments," Journal of Personality and Social Psychology, vol. 77, no. 6, pp. 1121-1134, 1999.
44. D. Williams and H. Thimbleby, "Using nomograms to reduce harm from clinical calculations," in IEEE International Conference on Healthcare Informatics, in press, 2013.
45. D. A. Grimes, "The nomogram epidemic: Resurgence of a medical relic," Annals of Internal Medicine, vol. 149, no. 4, pp. 273-275, 2008.
46. H. Thimbleby, P. Lee, and F. Thompson, "Analysis of infusion pump error logs and their significance for healthcare," British Journal of Nursing, vol. 21, no. 8, pp. S12-S22, 2012.
47. H. Thimbleby, A. Cauchi, A. Gimblett, P. Curzon, and P. Masci, "Safer "5-key" number entry user interfaces using differential formal analysis," in Proceedings BCS Conference on HCI, vol. XXVI. Oxford University Press, 2012, pp. 29-38.
48. A. Gimblett, R. Ruksenas, P. Oladimeji, A. Cauchi, Y. Li, P. Curzon, and P. Masci, "On formalising interactive number entry on infusion pumps," Electronic Communications of the EASST, vol. 45, pp. 1/14-14/14, 2011. [Online]. Available: http://journal.ub.tu-berlin.de/eceasst/article/view/654
49. W. C. Rontgen, "On a new kind of rays (translated into English)," British Journal of Radiology, no. 4, pp. 32-33, 1931.
50. R. Nader, Unsafe at Any Speed: The Designed-In Dangers of the American Automobile. Pocket Books, 1966.