Patient safety and interactive medical devices: Realigning work as imagined and work as done

Clinical Risk

Volumn 20, Issue 5, 2014, Pages 107-110

  Blandford, Ann ^a   Furniss, Dominic ^a   Vincent, Chris ^a  

^a UNIVERSITY COLLEGE LONDON   (United Kingdom)

Author keywords

human error; Medical device; patient safety; usability; workarounds

Indexed keywords

EID: 84921509688     PISSN: 13562622     EISSN: None     Source Type: Journal    
DOI: 10.1177/1356262214556550     Document Type: Article

References (24)

1. Francis R. Report of the Mid Staffordshire NHS foundation trust public inquiry: executive summary. Vol. 947. London: The Stationery Office, 2013.
2. Berwick D. Berwick review into patient safety. https://www.gov.uk/government/publications/berwick-review-into-patient-safety (2013, accessed 9 October 2014).
3. Crowch CT.Making the healthcare system truly ‘error tolerant’.Clin Risk. 2008;14 (4): 127-129
4. Hollnagel E. Why WAI is different from WAD. In: Presented at the third resilience health care net meeting, Middlefart, Denmark, 12–14 August 2014.
5. Fairbanks R,Wears R.Hazards with medical devices: the role of design.Ann Emerg Med. 2008;52:519-521
6. ISMP Canada. Fluorouracil incident root cause analysis. http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf (2007, accessed 9 October 2014).
7. President’s Information Technology Advisory Committee. Transforming healthcare through information technology. www.nitrd.gov/pubs/pitac/pitac-hc-9feb01.pdf (2001, accessed 9 October 2014).
8. Medical devices – application of usability engineering to medical devices. 62366. Geneva: International Electrotechnical Commission; 2007:
9. FDA. Draft Guidance for Industry and Food and Drug Administration Staff – applying human factors and usability engineering to optimize medical device design. http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm259748.htm (accessed 9 October 2014).
10. HE75: Human factors engineering – design of medical devices. Arlington, VA: AAMI; 2009:
11. Rajkomar A,Blandford A.Understanding infusion administration in the ICU through distributed cognition.J Biomed Inform. 2012;45:580-590
12. Furniss D, Blandford A and Mayer A. Unremarkable errors: low-level disturbances in infusion pump use. In: Proceedings of the 25th BCS conference on human computer interaction (HCI-2011), Newcastle Upon Tyne, UK, 4–8 July 2011, pp.197–204.
13. Vincent C. Guidelines for number entry interface design (infusion devices). Technical report IP003. http://www.chi-med.ac.uk/researchers/bibdetail-db.php?PPnum=IP003 (last updated 9 August 2013).
14. Koppel R,Wetterneck T,Telles JL, Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.J Am Med Inform Assoc. 2008;15 (4): 408-423
15. Furniss D, Masci P, Curzon P, et al. 7 Themes for guiding situated ergonomic assessments of medical devices: a case study of an inpatient glucometer. Appl Ergon. Epub ahead of print 20 June 2014. http://dx.doi.org/10.1016/j.apergo.2014.05.012.
16. Grissinger M.Preventing accidental infusion of breast milk in neonates.Pharm Ther. 2010;35 (3): 127-127
17. Debono D, Greenfield D, Black D, et al. Workarounds: straddling or widening gaps in the safe delivery of healthcare. In Proceedings of the 7th international conference in Organisational Behaviour in Health Care (OBHC), Birmingham, UK, 11–14 April 2010.
18. Nemeth CP,Brown J,Crandall B, The mixed blessings of smart infusion devices and health care IT.Mil Med. 2014;179 (8S):x- 4–10
19. The Health Foundation. Using safety cases in industry and healthcare http://tinyurl.com/chwg3a3 (accessed 25 August 2014).
20. Wiklund ME (ed). Medical device and equipment design: usability engineering and ergonomics. Boca Raton: CRC Press, 1995.
21. Hinrichs S. A systems approach to improving patient safety through medical device purchasing. https://www.repository.cam.ac.uk/handle/1810/238973 (2009, accessed 10 October 2014).
22. Gandillon R.Infusion pump reliability and usability: veteran's health administration examines differences between manufacturers.J Clin Eng. 2013;38 (1): 27-31
23. Nemeth C,Nunnally M,Bitan Y, Between choice and chance: the role of human factors in acute care equipment decisions.J Patient Saf. 2009;5 (2): 114-121
24. MHRA. Devices in practice: checklists for using medical devices. http://www.mhra.gov.uk/home/groups/dts-bs/documents/publication/con007424.pdf (2014, accessed 25 August 2014).