Safety and Quality in Health Care

•   Rattner, J. reported Intel Developer Forum, San Francisco. Sourced at 29 August 2008 from http://www.intel.com/pressroom/archive/releases/20080821comp.htm

• I thought you said you were gonna cut the red wire!
• Well I did, didn’t I?
• No! You cut the blue wire!
• Well I meant the red wire.

 Lethal Weapon 3 (1992)

The notion of making a mistake is so engrained in the human psyche that the study and practice of preventing a mistake is an industry in its own right. An industry which paradoxically also makes mistakes. Mistakes are quite simply unintentional errors or misunderstandings usually (but not always) associated with a potential or real adverse or negative outcome for someone or something. History is littered with large demonstrable mistakes with little or no impact on humankind but equally there are events where small errors of judgement that have led on to catastrophic outcomes.

The rush to embrace Clinical Information Systems in the heath care environment has as one of its drivers a reduction in adverse clinical events. The design of clinical systems is often more dependent on underlying operating software, vendor preferences, legacy system economies and less with ensuring that clinicians, often in highly stressful situations, do not make errors when interacting with systems.

Such errors leading on to new adverse outcomes that the implementations were intended to reduce in the first place. There are a multitude of points of interaction where design may be critical including graphical presentation, icon design and placement, standardisation of terminologies and screen actions, physical environment, interface tool design, warnings and alerts.

There are also less obvious sources of error including the increasing push for deeply embedded decision support algorithms that may as they become hidden from the clinician increase the opportunities for misinterpretation and poor outcomes.

This site explores analogies with non-clinical design process errors, anecdotal observations and reviews recent human factor research to suggest future health informatics research directions in applying human factors and systems designs through encouraging standardised clinical interface development based on evidence and analysis of errors as well as to suggest the need for greater uses of standardised interfaces across vendors.