Human Factors Design Research Articles

Human Factors Analysis, Design, and Evaluation of Engage, a Consumer Health IT Application for Geriatric Heart Failure Self-Care

ABSTRACTHuman factors and ergonomics (HFE) and related approaches can be used to enhance research and development of consumer-facing health information technology (IT) systems, including technologies supporting the needs of people with chronic disease. A multiphase HFE study of health IT supporting self-care of chronic heart failure by older adults is described. The study was based on HFE frameworks of “patient work” and incorporated the three broad phases of user-centered design: study or analysis, design, and evaluation. In the study phase, data from observations, interviews, surveys, and other methods were analyzed to identify gaps in and requirements for supporting heart failure self-care. The design phase applied findings from the study phase throughout an iterative process, culminating in the design of the Engage application, a product intended for continuous use over 30 days to stimulate self-care engagement, behavior, and knowledge. During the evaluation phase, a variety of usability issues through expert heuristic evaluation and laboratory-based usability testing were identified. The implications of our findings regarding heart failure self-care in older adults and the methodological challenges of rapid translational field research and development in this domain are discussed.

Using Human Factors Design Principles and Industrial Engineering Methods to Improve Accuracy and Speed of Drug Selection with Medication Trays

Using Human Factors Design Principles and Industrial Engineering Methods to Improve Accuracy and Speed of Drug Selection with Medication Trays

Promoting Patient Safety with Human Factors Methods

Medication management is a complex and mentally demanding endeavor performed by multiple individuals in diverse settings and at variable points in time. Achieving the goal of safe care delivery with optimized patient outcomes requires ongoing communication, coordination, and interaction between an array of technologies and roles across the health care continuum. Human factors principles and methods have the potential to substantially improve patient safety throughout this high-risk cycle. The purpose of this interactive discussion panel is to explore the medication management process from a sociotechnical perspective to identify specific challenges and vulnerabilities, and recommend strategies that leverage human factors processes and design principles to efficiently and effectively address safety critical issues.

A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.

To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems. We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken. A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users' work processes, and clinical decision support systems. Displaying an incomplete list of a patient's medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users' misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors. Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users' workflow expectations.

Development of a Veterinary Surgical Checklist

We describe a new surgical checklist for veterinary cardiologists based on the literature and the application of human factors design. The checklist was developed and iterated with subject-matter experts and was implemented for 4 months, during which use of the checklist was monitored, feedback was gathered, and a final survey was distributed to assess subjective experiences. Although developed for the cardiology team, the checklist also affected the anesthesia team by requiring information and responses to be transmitted across teams. Interviews, subjective reports, and observations pointed to the fact that the checklist engendered communication, particularly by requiring the thoughts and expectations of team members to be stated explicitly.

Industry-academic partnerships: an approach to accelerate innovation

BackgroundBiotechnology companies are process-driven organizations and often struggle with their ability to innovate. Universities, on the other hand, thrive on discovery and variation as a source of innovation. As such, properly structured academic-industry partnerships in medical technology development may enhance and accelerate innovation. Through joint industry-academic efforts, our objective was to develop a technology aimed at global cervical cancer prevention. MethodsOur Center for Medical Innovation assembled a multidisciplinary team of students, surgical residents, and clinical faculty to enter in the University of Utah's annual Bench-to-Bedside competition. Bench-to-Bedside is a university program centered on medical innovation. Teams are given access to university resources and are provided $500.00 for prototype development. Participation by team members are on a volunteer basis. Our industry partner presented the validated need and business mentorship. The team studied the therapeutic landscape, environmental constraints, and used simulation to understand human factors design and usage requirements. A physical device was manufactured by first creating a digital image (SOLIDWORKS 3D CAD). Then, using a 3-dimensional printer (Stratasys Objet30 Prime 3D printer), the image was translated into a physical object. Tissue burn depth analysis was performed on raw chicken breasts warmed to room temperature. Varying combinations of time and temperature were tested, and burn depth and diameter were measured 30 min after each trial. An arithmetic mean was calculated for each corresponding time and temperature combination. User comprehension of operation and sterilization was tested via a participant validation study. Clinical obstetricians and gynecologists were given explicit instructions on usage details and then asked to operate the device. Participant behaviors and questions were recorded. ResultsOur efforts resulted in a functional battery-powered hand-held thermocoagulation prototype in just 72 d. Total cost of development was <$500. Proof of concept trials at 100°C demonstrated an average ablated depth and diameter of 4.7 mm and 23.3 mm, respectively, corresponding to treatment efficacy of all grades of precancerous cervical lesions. User comprehension studies showed variable understanding with respect to operation and sterilization instructions. ConclusionsOur experience with using industry-academic partnerships as a means to create medical technologies resulted in the rapid production of a low-cost device that could potentially serve as an integral piece of the “screen-and-treat” approach to premalignant cervical lesions as outlined by World Health Organization. This case study highlights the impact of accelerating medical advances through industry-academic partnership that leverages their combined resources.

User acceptance of observation and response charts with a track and trigger system: a multisite staff survey.

To examine user acceptance with a new format of charts for recording observations and as a prompt for responding to episodes of clinical deterioration in adult medical-surgical patients. Improving recognition and response to clinical deterioration remains a challenge for acute healthcare institutions globally. Five chart templates were developed in Australia, combining human factors design principles with a track and trigger system for escalation of care. Two chart templates were previously tested in simulations, but none had been evaluated in clinical practice. Prospective multisite survey of user acceptance of the charts in practice. New observation and response charts were trialled in parallel with existing charts for 24hours across 36 adult acute medical-surgical wards, covering 108 shifts, in five Australian states. Surveys were completed by 477 staff respondents, with open-ended comments and narrative from short informal feedback groups providing elaboration and context of user experiences. Respondents were broadly supportive of the chart format and content for monitoring patients, and as a prompt for escalating care. Some concerns were noted for chart size and style, use of ranges to graph vital signs and with specific human factors design features. Information and training issues were identified to improve usability and adherence to chart guidelines and to support improved detection and response for patients with clinical deterioration. This initial evaluation demonstrated that the charts were perceived as appropriate for documenting observations and as a prompt to detect clinical deterioration. Further evaluation after some minor modifications to the chart is recommended. Explicit training on the principles and rationale of human factors chart design, use of embedded change management strategies and addressing practical issues will improve authentic engagement, staff acceptance and adoption by all clinical users when implementing a similar observation and response chart into practice.

Evaluating the Usability and Perceived Impact of an Electronic Medical Record Toolkit for Atrial Fibrillation Management in Primary Care: A Mixed-Methods Study Incorporating Human Factors Design.

BackgroundAtrial fibrillation (AF) is a common and preventable cause of stroke. Barriers to reducing stroke risk through appropriate prescribing have been identified at the system, provider, and patient levels. To ensure a multifaceted initiative to address these barriers is effective, it is essential to incorporate user-centered design to ensure all intervention components are optimized for users.ObjectiveTo test the usability of an electronic medical record (EMR) toolkit for AF in primary care with the goal of further refining the intervention to meet the needs of primary care clinicians.MethodsAn EMR-based toolkit for AF was created and optimized through usability testing and iterative redesign incorporating a human factors approach. A mixed-methods pilot study consisting of observations, semi-structured interviews, and surveys was conducted to examine usability and perceived impact on patient care and workflow.ResultsA total of 14 clinicians (13 family physicians and 1 nurse practitioner) participated in the study. Nine iterations of the toolkit were created in response to feedback from clinicians and the research team; interface-related changes were made, additional AF-related resources were added, and functionality issues were fixed to make the toolkit more effective. After improvements were made, clinicians expressed that the toolkit improved accessibility to AF-related information and resources, served as a reminder for guideline-concordant AF management, and was easy to use. Most clinicians intended to continue using the toolkit for patient care. With respect to impact on care, clinicians believed the toolkit increased the thoroughness of their assessments for patients with AF and improved the quality of AF-related care received by their patients.ConclusionsThe positive feedback surrounding the EMR toolkit for AF and its perceived impact on patient care can be attributed to the adoption of a user-centered design that merged clinically important information about AF management with user needs. This study demonstrates the utility of a human factors approach to piloting and refining an intervention prior to wide-scale implementation.

Heart—A Proposed Method for Achieving High Reliability in Process Operation by Means of Human Factors Engineering Technology

One of the last remaining hurdles to be overcome in the design of safe, reliable systems is the human being. For some time now safety and reliability engineers have recognised that they not only need to be able to assess the likelihood and impact of human unreliability but would benefit from a working knowledge of how to apply human factors engineering technology to optimise overall systems design.Most safety and reliability engineers also appreciate that beyond the immediate superficial level human engineering principles are not only difficult to enunciate, understand or evaluate, but are occasionally costly to apply. Often sub-systems which are manifestly well-engineered from a human factors standpoint fail to achieve the sort of total reliability expected when integrated with other sub-systems, to the consternation of the process and system designer. When this happens the operator finds it hard to believe that such a mismatch could have occurred because of a high level failure of human engineering, and will often resort to remedies from the management “tool-kit”, rather than the human factors design database.This paper attempts to minimise the likelihood of such outcomes by identifying the relevant factors, which from the author's experience, are considered likely to facilitate the achievement of high man-machine system reliability It demystifies human factors technology by assigning relative weights to the factors, identifying Impacts and suggests a set of human error data which should assist assessors and designers in the achievement of high systems reliability.

Human Factors Research and Design Trends for the Modern Exam and Hospital Room

Although much research has been conducted on the impact of the electronic health record (EHR) and health information technology (HIT) on provider-patient interaction, challenges persist on how to effectively integrate these tools into healthcare environments, while maintaining patient-centered care. Panelists will present and discuss their experience relating to: the introduction of new technology and how it changes the nature of work; the positive impact of greater focus on the patient; the nature of interruptions and strategies to reduce their negative impact; enhancing the workflow of medication ordering; and designing collaborative spaces considering all relevant stakeholders (patient care team, patients, family members). These topics represent some of the latest human factors research and design trends with a common goal: advancing the design of the modern healthcare environment, with consideration of the additional complexity introduced by evolutionary changes in clinical information systems and HIT.

The Wisdom of Crowds.

The Wisdom of Crowds.

Usability Analysis and Redesign of Infusion Pump User Interface

Infusion pump is a vital medical device used to continually deliver medications or fluids to the patient's body in a controlled manner. This device is capable of delivering predetermined amounts of fluids and may be used to deliver nutrients, blood, or medications, such as antibiotics, pain medications, and chemotherapeutic. However, due to poorly designed user interface, misuses can be prevalent and might lead to serious medical errors, such as dosing errors. The aim of this research is to (1) identify usability problems of infusion pumps commonly used in oncology clinics and other outpatient settings through interviews and heuristic evaluation; (2) propose new designs to address the problems and eventually improve performance. During a heuristic evaluation, three major violations of human factors design principles were identified: (1) lack of feedback about the patient and the patient condition? Not sure if this is a violation; (2) poor flexibility and efficiency of use; (3) the position of start/stop button can limit the control over the task. We proposed a new interface design to overcome these issues.

Human factors engineering and design validation for the redesigned follitropin alfa pen injection device

Objectives: To demonstrate, using human factors engineering (HFE), that a redesigned, pre-filled, ready-to-use, pre-asembled follitropin alfa pen can be used to administer prescribed follitropin alfa doses safely and accurately.Methods: A failure modes and effects analysis identified hazards and harms potentially caused by use errors; risk-control measures were implemented to ensure acceptable device use risk management. Participants were women with infertility, their significant others, and fertility nurse (FN) professionals. Preliminary testing included ‘Instructions for Use’ (IFU) and pre-validation studies. Validation studies used simulated injections in a representative use environment; participants received prior training on pen use.Results: User performance in preliminary testing led to IFU revisions and a change to outer needle cap design to mitigate needle stick potential. In the first validation study (49 users, 343 simulated injections), in the FN group, one observed critical use error resulted in a device design modification and another in an IFU change. A second validation study tested the mitigation strategies; previously reported use errors were not repeated.Conclusions: Through an iterative process involving a series of studies, modifications were made to the pen design and IFU. Simulated-use testing demonstrated that the redesigned pen can be used to administer follitropin alfa effectively and safely.

Mental models: a basic concept for human factors design in infection prevention

Much of the effort devoted to promoting better hand hygiene is based on the belief that poor hand hygiene reflects poor motivation. We argue, however, that automatic unconscious behaviour driven by 'mental models' is an important contributor to what actually happens. Mental models are concepts of reality--imaginary, often blurred, and sometimes unstable. Human beings use them to reduce mental load and free up capacity in the conscious mind to focus on deliberate activities. They are pragmatic solutions to the complexity of life. Knowledge of such mental processes helps healthcare designers and clinicians overcome barriers to behavioural change. This article reviews the concept of mental models and considers how it can be used to improve hand hygiene and patient safety.

Human Factors in the Design of Medical Simulation Tools

This paper describes the human factor design issues relevant to medical simulation systems. Decision making in medical domains is an increasingly complex task that involves a number of stakeholders, sub-specialties and technologies. Medical simulation creates a lifelike situation for individuals to practice decision-making and procedural activities in a safe environment for the patients and professionals where it involves simulated human patients, emergency response and simulated animation. Evidence suggests that medical simulation improves the effectiveness, safety, and efficiency in health care services. Moreover, it has been shown to consistently deliver significant value to the organization, staff, or students in decision-making. Although medical simulation provided ideal approaches for addressing healthcare issues, the number of successful software implementation and development is relatively small compared with other established engineering disciplines, such as the manufacturing industry. Software quality models in particular offer the opportunity to systematically assess the level of compliance of software systems with industry standards. In addition, applying software quality models increase the customer satisfaction and decrease the quality cost.

Human Factors Design, Verification, and Validation for Two Types of Control Room Upgrades at a Nuclear Power Plant

This paper describes the NUREG-0711 based human factors engineering (HFE) phases and associated elements required to support design, verification and validation (V&amp;V), and implementation of a new plant process computer (PPC) and turbine control system (TCS) at a representative nuclear power plant. This paper reviews ways to take a human-system interface (HSI) specification and use it when migrating legacy PPC displays or designing displays with new functionality. These displays undergo iterative usability testing during the design phase and then undergo an integrated system validation (ISV) in a full scope control room training simulator. Following the successful demonstration of operator performance with the systems during the ISV, the new system is implemented at the plant, first in the training simulator and then in the main control room.

Clinical utility of an observation and response chart with human factors design characteristics and a track and trigger system: study protocol for a two-phase multisite multiple-methods design.

BackgroundClinical deterioration of adult patients in acute medical-surgical wards continues to occur, despite a range of systems and processes designed to minimize this risk. In Australia, a standardized template for adult observation charts using human factors design principles and decision-support characteristics was developed to improve the detection of and response to abnormal vital signs.ObjectiveTo describe the study protocol for the clinical testing of these observation and response charts (ORCs).MethodsWe propose a two-phase multisite multiple-methods design to test the initial clinical utility of the charts in 10 hospitals of differing types and sizes across state jurisdictions in Australia. Data collection in the first phase includes user surveys, observations and field notes by project officers, handover de-briefs (short interviews with small groups of staff), and an audit of ORC documentation completion compared to the site’s existing observation chart. For the second phase, data will be collected using a retrospective audit of observation documentation from the previous hospital observation chart, prospective audit of observation documentation following implementation of the selected ORC, user focus groups, observational field notes, and patient outcome data from routinely collected organizational data sources.ResultsSite selection and preparation, project officer training, chart selection and implementation, participant recruitment, and data collection has been completed and the analysis of these results are in progress.ConclusionsThis detailed description of these study methods and data collection approaches will enable a comprehensive assessment of the clinical utility of these newly developed track and trigger charts and will be useful for clinicians and researchers when planning and implementing similar studies. Potential methodological limitations are also noted.

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use.

Chemotherapy is an effective treatment in the fight against many cancers. Medication errors in oncology can be particularly serious given the narrow therapeutic window of antineoplastic drugs and their high toxicities. Computerized prescriber order entry (cpoe) has consistently been shown to reduce medication errors and adverse drug events in various settings, but its use in the oncology setting has not been well established. To gain a better understanding of the meaningful use of cpoe systems in the outpatient chemotherapy setting, we undertook a systematic review of systemic therapy cpoe. A province-wide expert panel consisting of clinical experts, health information professionals, and specialists in human factors design provided guidance in the development of the research questions, search terms, databases, and inclusion criteria. The systematic review was undertaken by a core team consisting of a medical oncologist, nurse, pharmacist, and methodologist. The medline, embase, cinahl, and compendex databases were searched for relevant evidence. The database searches resulted in 5642 hits, of which 9 met the inclusion criteria and were retained. In the oncology setting, cpoe systems generally reduce chemotherapy medication errors; however, specific types of errors increase with the use of cpoe. These systems affect practice both positively and negatively with respect to time, workload, and productivity. Despite the paucity of oncology-specific research, cpoe should be used in outpatient chemotherapy delivery to reduce chemotherapy-related medication errors. Adoption by clinicians will be enhanced by cpoe processes that complement current practice and workflow processes.

Low-hanging fruit for human factors design in infection prevention—still too high to reach?

Human factors design interventions have been suggested to mitigate infection risk in health care. Among such solutions, many are easily identified and theoretically simple and quick to realize. These are called low-hanging fruit. We present a case of infection risk associated with syringe manipulation that could easily be solved by introducing user-centered design solutions. Yet, organizational complexity makes implementation of such solutions hardly reachable. We therefore advocate embedding human factors macroergonomic expertise on an organizational level.

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes.