Joey Chen, To Err is Human ─ Human Factors in the Health Care System, C8
Imagine this. It is midnight. You’re a doctor in an emergency room and you have been working non-stop for the past 30 hours. A patient has come in because of a terrible car accident. You came rushing to the patient, set up the ventilator, a machine that helps breathing, as soon as possible and stated to perform CPR. Six minutes later, the patient died. What could be the reason? Any guess? Actually, the cause of his death was that you forget to plug the ventilator. You forget about the plug! Sounds ridiculous right? But unfortunately it’s a true story.
So why did this tragedy even happen in the first place? Even we know we have to plug the machine for it to work. So it’s not about medical knowledge at all. It’s the hazardous environment and working circumstances that led to this medical error.
As a doctor, as a mortal human being, to err is inevitable. Fortunately, we have human factors here to help us make things right. So today I’ll introduce some examples of human factors in our healthcare system to you and tell you why it’s important to all of us.
So first thing first, what exactly are human factors? Simply put, this is how we interact with machines and all the different devices we use every day. The blue part is how the machine works and the yellow part above is how human process information and make decisions. Human factors focus on the green part in between, which is the interface that serves as a friendly bridge between the user and the device.
The concept of human factors went into full bloom during World War I. That was a time when a mistake made by a pilot of a bomber could cost millions of lives. So they designed the seat and panel in aircrafts according to human factors to help pilots keep their attention focused and avoid possible mistakes. The same thing can be applied to the hospital too.
The hospital is no safer place than a battle field with people dying from medical errors every day. According to a study in the United States, at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented. And that is the 5th leading cause of death in the USA.
In Taiwan, the hazards in our hospitals are even worse. The three main hazards including long working hours, taking night shifts often, and having too many patients to care for make Taiwanese doctors exhausted and therefore also endangering patients’ safety.
In 2014, Taiwanese doctors work 81 hours per week averagely while the most tiresome physicians in the USA work about only 65 hours per week. And from another study we can find out that a single night of continuous sleep deprivation, in other words taking extended night shifts, causes doctors’ performance similar to those who have a blood alcohol level of 0.1, which is quite close to that of a drunken driver.
So it’s not surprising that doctors in Taiwan are prone to conduct medical errors. They may be exhausted and somewhat drunk. Then how can we ensure the doctors to do the right thing under such hazardous working environment? Here is where human factors step in! It helps prevent possible medical errors by designing the operational interface according to human’s natural instincts and habit.
Here are some examples. First is a good example of how human factors work in the healthcare system. This is a defibrillator. You’ve all seen this in a movie right? Now when a fatigue doctor with serious sleep deprivation comes to the front of a defibrillator, he or she can simply follow the SOP as there are numbers beside the buttons needed to be pressed. The first step of course is to press the power button of the defibrillator. Second, the analyze button to see if the patient is suitable for defibrillation. And third, the Shock button. With this user-friendly interface, medical errors like forgetting to plug can be reduced even if the doctor is exhausted.
Next is an inappropriate example of design regarding human factors which can easily cause medical errors. Here are two identical tube connectors that may cause improper connection. Say if today I want to give the patient oxygen, O2, but I misconnect the tube so instead he got carbon dioxide, CO2, because the tubes look exactly the same. That would be a disaster. So what can we do? The solution is simple. We design different colors or different type of tubes for each connector. Problem solved.
To wrap it up, human factors should be an essential element when it comes to designing our healthcare system. It is an important key to help secure the health for all of us under today’s hazardous circumstances. And also it is as simple as changing the color of the tubes to provide a friendly interface for the healthcare workers.
So if we can just all pay a little more attention to the common errors in our healthcare system, use our creativity to find out the solution regarding human factors, we will be able to make the healthcare system in Taiwan a safer and a better place.