Health Care Systems & Emotional Design

Question 1

what is the Therac-25

Answer 1

• medical linear accelerator that delivers radiation beam to patient- used to remove remnants of cancerous growths or tumours after surgery- treatment usually involves many low-energy dosages over successive treatment sessions- machine controlled via DEC VT100 terminal connected to PDP-11 mainframe computer located in another room- software (not hardware) largely responsible for maintaining safety, including monitoring electron-beam scanning- Therac-25 software modified from Therac-20

Question 2

the two modes of therac-25

Answer 2

1. Lo-Energy mode.mode: electron beam of about 200 rads aimed directly at patient andsent off in a short burst; used to treat shallow tissue2. Hi-Energy X-ray mode.uses full 25 million electron volt capacity of the machine;used to reach deeper tissue• for “electron mode”, technician types “e”; for “X-ray mode”, technician types “x”• for mode 2, beam switch occurs, arm moves tungsten plate between beam sourceand patient• beam passes through plate  transformed into X-ray

Question 3

the case of Ray Cox and Therac-25

Answer 3

-went in for 9th lo-energy electron beam treatment for shoulder-technician entered prescription in terminal, but kept getting “malfunction 54” error-sheet listed it as a “dose input 2” error (too hi or too low?)-operator did this 3 times, same error-Ray then felt repeated burning/stabbing pains and pulled himself off table-DIED of complications from overdose 5 mo. later-problem not diagnosed until 3 weeks later-same thing had happend to another patient, six similar overdoses in Georgia Washington and Canada!-machine recalled!!!

Question 4

causes of Therac-25 overdose

Answer 4

-software bug (latent error).if command sequence entered too quickly, race condition occured, two sets of instructions, first one that arrived set the mode.arm withdrew correctly for electron beam mode… but beam switch never occurred!-machine left in a hybrid proton beam mode, delievered >125x normal radiation-poor safety engineering.error condition detected, but did not inform operator (why not, machine configured incorrectly?).operator’ manual also did not explain malfunction codes (operators made own sheet)-tech’s behavior erroneous.misinterpreted situation, chose inappropriate procedure-lax safety culture-inadequate reporting structure in company, legislation

Question 5

iatrogenic injury

Answer 5

caused by a physician or other health-care provider (sort of a revenge effect)

Question 6

To err is human: building a safer health system, summary of results, criticisms

Answer 6

-released by Institute of Medicine-3-4% rate of adverse effects caused by treatment!!-of these, 58% caused by error, 14% fatal-estimated 44-98k deaths/year due to iatrogenic injuries in hospitals (8th leading cause of death in US!!!!)-cost $29 billion per year!!!-most iatrogenic injuries due to error, which are preventablecriticisms: [X] eliminating AEs may not prevent deaths[X] NY data focused on patients w/ high AE likelihood

Question 7

IOM report results, consequences

Answer 7

President Clinton directed task force to develop a strategy-Patient Safety & Quality Improvement Act enacted in 2005; created blame-free adverse event reporting-2009, released report To Err is Human – To Delay is Deadly -argued for greater change-use of a checklist reduced infections by 66%! saving 1.5k lives and $200m over 18 mo!

Question 8

why study errors?

Answer 8

psychologists: to create theories; understand human behaviourengineers/designers: to assess systems; prevent further errors, reduce their probability,or lessen their effectsmedical scientists: to understand effects of treatments; to find and punish the negligent(those who fail to meet the “ordinary standard of care”)

Question 9

potential problems causing medical error

Answer 9

-intrumentation.hi tech instruments are complex; many fucking controls-labs/test reports.may be ignored, misplaced, forgotten.results may vary.e.g. “white-coat hypertension” (elevated blood pressure only found in clinical situations, due to patient anxiety) affects 5% patients-decision-making process.based on patient self-reports (what is considered nothing to worry about? severe enough for attention?).affected by biases-medication & prescriptions.contraindications, side effects, interactions.sound-alike or easily confused drug names.poor writing (use TALL MAN capital letters).abbreviations misread-reporting.errors often not reported b/c AEs often have no lasting harmful effects.malpractice insurance expensive, errors told to deny/defend.can lead to “defensive medicine!!!” practices to safeguard against patients.should assume errors occur, so can study prevent reduce, but nobody wants to admit it!

Question 10

types of medical errors

Answer 10

more than 75% of errors were PREVENTABLE-most errors due to mismanagement of patients–not due to rare conditions or negligence1. treatment: 60.5%-performance error-delayed treatment/inappropriate care2. diagnosis: 21.9%-failure to employ indicated tests-misread lab results-failure to act on results of monitoring/testing3. Preventive: 16.2%-inadequate monitoring or follow-up4. Other: 1.2%-equipment failure-poor comunication

Question 11

Lesar et al. (1990) medication error in NY teaching hospital

Answer 11

-overall rate: 3 per 1000 prescriptions, 1.8 significant-most common types• overdose: 41.8%• under dose: 16.5%• allergy: 12.9%• dosage form: 11.6%• wrong drug: 5%• duplicate therapy: 5% • wrong route: 3.3% (wrong organ or skin)• wrong patient!: 0.4%

Question 12

patient safety in canada study, baker et. al (2004)

Answer 12

reviewed charts from various provinces in canada-AE rate 7.5%!!-36.9% judged preventable-mortality rate 20.8%!!!! of the AE rate

Question 13

Loepelmann & Hamilton (2001): Medical Error Description study

Answer 13

-questionnaires given to 97 medical residency candidates-25 qs on perceptions of errors-most common error type:.slip: 60.3%.mistake: 20.6%.both: 7.4%severity of most errors.slight/no treatment: 45.6%.slight/minor treatment: 26.5%.none apparent: 23.5%.moderate: 1.5%most problematic shift.midnight-6am: 41%.6pm-midnight: 26.2%percentage of problems due to medication: 49%percentage of errors due to miscommunication: 45.7%most problematic meds: antibiotics: 32.6%why errors not reported?-minor/no consequences/problem fixed: 61.4%fear of consequences: 22.8%

Question 14

barriers to change in medical profession (errors)

Answer 14

-complexity.technology, operations, relationships-culture of shame/blame.physicians held to standard of perfection.errors seen as result of negligence, treated as “dirty secrets-misguided professionalism.overemphasis on technical skill at expense of training in teamwork or “soft” sciences-lack of organizational control.hospital/state/national oversight is piecemeal.little standardization (“critical condition” vs “serious condition”?) terms-inadequate development/use of IT-lack of organizational commitment to safety.no formalized, systematic review process.individualized review process: cause in system not determined (M & Ms, see below)M and Ms: morbidity and mortality.if there was a shitty procedure, and someone makes an error: all medicine people get together and the last person who touched it has to confess and explain why they made the mistake and apologize….Wow. Very punitive, humiliating

Question 15

error solution: disclosure & apology

Answer 15

-disclose to patient that you made an error, and apologize.UofMichigan, existing claims/lawsuits dropped from 262 to 83.UofIllinois, malpractice filings dropped by half.Colorado, malpractice claims dropped by 50%.2009, 36 states had “apology laws,” malpractice payments in these states 14-17% lower

Question 16

Systems approach: 6 levels

Answer 16

1. Physical devices & ergonomics: the design & immediate environment2. Individual behavior: the actor3. Team & Group behavior: the social context4. Organizational & Management: the structure of supervision5. Legal & regulatory rules: laws and rules6. Societal & Cultural pressures: the demands in the larger contextALSO: consider INTERACTIONS among components

Question 17

Systems approach: 1. Physical devices & ergonomics (KNOW RESEARCH FIELDS)

Answer 17

1. Physical devices & ergonomics: THE DESIGN & THE IMMEDIATE ENVIRONMENT- research fields: industrial design, engineering; anthropometry- design model/designer’s conceptual model (Have to convey how it works to consumers so they have correct mental models)- design of displays, controls, etc.

Question 18

Systems approach: 2. Individual behavior (KNOW RESEARCH FIELDS)

Answer 18

2. Individual behavior: the actor- research field: psychology (cognitive, human factors)- ultimate “cause” of errors: may produce “human error” - affected by memory, choice of heuristics/algorithms

Question 19

Systems approach: 3. Team & Group behavior (KNOW RESEARCH FIELDS)

Answer 19

3. Team & Group behavior: the social context- research fields: social psychology, sociology- Redundancy cannot be applied among people; diffusion of responsibility decreasesreliability of group- in a hierarchical group, those at upper levels may lack technical expertise to confirmwork done properly by those at lower levels- affected by factors like group polarization, groupthink, etc.

Question 20

Systems approach: 4. Organizational & Management (KNOW RESEARCH FIELDS)

Answer 20

4. Organizational & Management: the structure of supervision- research fields: industrial/organizational (“I/O”) psychology, management theory - create policy, which affects entire organizatione.g., decision to go to 24-hour shiftwork, investment in design, should errors be punished or investigated? (ppl working graveyard shift often make errors, what do we do? fire them? change policy?)- responsible for development of safety culture (chernobyl!)- about 20% of profitability is determined by error management culture (van Dyck etal., 2005)

Question 21

Systems approach: 5. Legal & regulatory rules

Answer 21

5. Legal & regulatory rules: laws and rules- research fields: forensic psychology, legal scholars, governments? - restrict what can/cannot be done, via laws- problems:• too many rules: can’t know them all (if you break a law you didn’t know, still punished!!)• legislation lags behind technological developments (file-sharing)• letter of the law, not the spirit, tends to be observed• in a lawsuit or trial, blame often must be assigned (falling at the feet of theINDIVIDUAL) (people often want to blame an individual, not a system!)

Question 22

Systems approach: 6. Societal & Cultural pressures

Answer 22

6. Societal & Cultural pressures: the demands in the larger context- research fields: cultural anthropology, sociology, economics- includes economic and political pressures- cultural beliefs provide a context

Question 23

implications of the systems approach:

Answer 23

people will make errors, so change other parts of the system: • redesign (or improve) human/machine interfaces• reduce workload, enhance wellness• improve communications• decrease pressure to stay on time/on budget; foster safety culture • consider safety legislation/promote awareness (Drinking and driving is bad! But wait, we make these advertisements and people still doing it…)

Question 24

UX

Answer 24

User experience.a person’s subjective experience when using a product, system, or service.

Question 25

3 levels of processing a design

Answer 25

BEST designs enjoyable on ALL THREE levels1. Visceral (or reactive) level:-e.g. attractive- hardwired, perceptually based; processes simple stimuli (reflexes)-your guts, basic physiological response- has “proto-affect”: immediate positive or negative value- includes sensory pleasure, aesthetics (e.g., colour, texture)e.g., riding a rollercoaster (heights, falling, speed)2. Behavioural (or routine) level:-e.g. functional and usable- based in unconscious expectations and automatic behaviours- good “feel” w/ interaction (stick shift of mazda miata)- locus of primitive emotions; includes usability- includes usability, performance (e.g., ergonomics)e.g., working with a fine Shun knife (pleasure of using a good tool effectively;skilled accomplishment)3. Reflective level:-e.g. high in prestige-deepest, most sophisticated- based in intellect, and higher-order cognitive functions, including metacognition, consciousness, and self-reflection- has fully fledged, complex emotions- includes self-identity, socialization (e.g., collective identity) e.g., enjoyment of literature or art

Question 26

impacts of emotions in design

Answer 26

-negative emotional state: people tend to focus on a topic or task at hand, concentrating on details and avoiding distraction-moderate-intensity positive emotional state: people more creative, overlook minor problems (better problem solvers, more divergent thinking)

Question 27

pros and cons of emotional design (by don norman)

Answer 27

CHECK provides a role for cognition in emotional design (for designers)[X] criticized as overly reducing the complex nature of design

Question 28

4 dimensions of pleasurable products, Patrick Jordan (2000), pros/cons

Answer 28

physio-pleasure.applies to one’s body and sensory organse.g., shape of telephone handset, texture of pen, toothbrush, new clothes, new car smell.controller vibration in flowerpsycho-pleasure.applies to one’s cognitive and emotional reactions e.g., really engaging video game, “killer app” softwaresocio-pleasure.applies to one’s connection to other people; social identity/interactione.g., using social media apps on your smartphone to connect with friendsideal-pleasure.applies to one’s valuese.g., drinking fair trade coffee, eating organic food, reading the Times, not theEnquirerCHECK provides framework about pleasure that can aid design process[X] focuses on simplistic unpleasant-pleasant dimension of affect, not the full range of emotions

Question 29

Kansei (“sensory” or “emotional” engineering)

Answer 29

-created by Mitsuo Nagamachi-development methodology that translates customers’ feelings and emotions about products to design SOLUTIONS and concrete design PARAMETERS-explicitly relates emotions to product design, to create a more satisfactory experience

Question 30

Kansei case study: Mazda Miata

Answer 30

“zero-level concept” design goal determined to be unification of the human-machine unit (HMU)• surveyed young peoples’ attitudes and driving behaviours• driver behaviour also observed• data analyzed to create functional, usable, and pleasurable designse.g., used sound frequency analysis to determine young peoples’ preference for exhaust sound, and tried over 100 vent pipe designs to create the right “exhaust note,” which suggests the right time to shift

Question 31

neuroergonomics

Answer 31

study of the brain and behaviour in work contexts- advances the understanding of brain function and neural basis of cognitive processes and performance in real-world tasks- applies existing and emerging knowledge of human performance and brain function to design systems for safer and more efficient operation- research has increased with greater availability of brain imaging technology- although HF/E has been strongly influenced by the functionalist perspective of cognitivepsychology and cognitive science, cognitive neuroscience has allowed recognition that an embodied mind interacts in a physical world

Question 32

HF future directions

Answer 32

problems with cognitive psychology  cognitive engineering:- abstract theories studied, instead of CONCRETE applications- subtle psychological effects have been most studied; more info on ROBUST effects needed - principles of cognition rarely influence machine design!- designers are largely UNAWARE of cognitive principles