The Texas Health CoLab Learning Series supports Austin’s health innovation ecosystem by offering classes, seminars and immersive workshops that are open to all Texas Health CoLab participants as well as the general public. Seminars usually occur the last Thursday of the month and are livestreamed to several locations across Texas.
This post is by Vandana Dubakula, a Workspaces @ Texas Health CoLab intern.
For a spooky October installment of the Texas Health CoLab Learning Series, Michael Wiklund, general manager at Emergo by UL and a board-certified human factors professional, provided insight into the medical error epidemic and the role that human factors engineering plays in reducing errors.
Wiklund began by providing background on medical error in the United States. He said medical error is the third-leading cause of death after heart disease and cancer and that 50,000 to 95,000 people die per year due to preventable medical errors. In a health care setting, the causes of these errors can be attributed to providers’ incorrect judgment calls or poorly designed technology. As a human factors engineer, Wiklund has encountered many instances in which incorrect use of medical devices has led to errors.
Wiklund used case examples to illustrate how technology design combined with human operators can lead to errors. He presented one anecdote in which a misconnection between the leads — the metal prongs of wires — on a child’s chest and an electric power cord (rather than a cardiac monitor) led to the child’s death.
Many injurious and deadly errors occur because mistakes are not detected at the appropriate time. Wiklund highlighted the magnitude of the epidemic with statistics: He said 15% of medical errors occur due to medical device use errors, which equates to over 37,000 deaths per year.
Next, Wiklund focused on defining human factors engineering. This type of engineering involves applying what is known regarding human capabilities and limitations to the design of products, processes, systems and work environments. Human factors engineers can work in any field, including health care, and reduce errors through a systemic set of tasks. Some include determining the users’ needs instead of assuming them, discerning the use environment, conducting use-related risk and designing a user interface. All these steps are necessary to build a product or environment that is actually functional and productive for the user.
Wiklund then elaborated on the extent of human factors engineering required in a given situation. He outlined a few components that determine the amount of engineering that is necessary.
The first is device complexity, in which he used the example of a pen injector vs. an MRI scanner. The latter is a much more complex device, so more engineering may be necessary to ensure that no device use errors are made.
The next component is the seriousness of harm that can arise due to use errors. Wiklund compared a blood pressure monitor to a dialysis machine as an example. Even menial errors in the use of a dialysis machine can cause detrimental effects, while the same is not true for a blood pressure monitor.
He also explained that user expectations and levels of interaction with a device influence the extent of human factors engineering needed for a product. In the example regarding misconnection of wires, the solution to reduce chances for medical error came via reshaping the connectors to prevent misconnection in the first place. In this case, the complexity of the wires and cardiac monitor is high, as is the degree of harm that occurs as a result of device misuse. Thus, this involves a high level of human factors engineering.
Wiklund ended with a description of the report outline that human factors engineers use to explain the type of work they did for a device and why that would lead to better outcomes. The report requires descriptions of the intended device users, uses of the device, use environments and a summary of known use problems. The report also needs an analysis of hazards and risks connected to device use. The thoroughness of the report ensures that the engineer has thought through all the risks associated with the device and created solutions to minimize potential user errors, and therefore injury or death.
Overall, Wiklund’s presentation was informative and easy to follow. He showed his extensive knowledge of this field and combined statistical and anecdotal information with humor to keep the audience interested and engaged. His talk shed light on the medical error epidemic and the importance of mitigating this error for better patient outcomes. He outlined the effects of human factors engineering in various fields, which allowed the audience to be more aware and educated on this topic.
View the recording of Wiklund’s seminar to learn more.
To find out about upcoming seminars and to register, please visit the Texas Health CoLab Learning Series website.