Awalin Sopan, Catherine Plaisant,
Seth Powsner, Ben Shneiderman
Human-Computer Interaction Lab &
Department of Computer Science,
University of Maryland
http://www.nytimes.com/2002/06/18/health/oops-wrong-patient-journal-takes-on-medical-mistakes.html
Mrs. Morris, 67
Mrs. Morrison, 77
They were in same hospital floor.
Mrs. Morris was taken to the
operation room for the heart surgery
•
A drug administered to
wrong patient
•
Reading of wrong
patients’ test results
•
Patients miss needed
treatment
•
etc.
multitasking
fatigue
interruption
urgency
long work-hours

Error Classification
 what are the error-scenarios clinicians face

Task Analysis
 which stage is more susceptible to a
particular type of error

27 Specific Techniques
 what to do, and then how to do it
Mistake
Slips
Failure to
recognize
Mistake
Slips
Failure to
recognize
Recalling the wrong
patient due to short
term memory failure,
name similarity,
unfamiliarity with the
patient, fatigue.
Mistake
Slips
Failure to
recognize
Mechanical errors such
as wrong key press,
mouse slip, or errors
due to unreadable
fonts and too small
button size.
Mistake
Slips
Failure to
recognize
Failures to detect errors
due to interruptions,
multitasking, absence
of relevant information.
 Facilitate recall:
▪ Provide more context: room number, photo,…
 Avoid confusion:
▪ Emphasize the salient features: age, chief
complaint,…
▪ Use at least two sources of
identification: name, medical record number,…
Poor recall strategy,
more mistakes




Allow sorting
Always show patient’s full name
Scan RFID to retrieve the patient
Use indoor location to retrieve the patients
 Improve target-selection
 Improve text-readability
 Highlight target under cursor
Poor selection
mechanism, more slips


Highlight row under cursor
Use an icon-based 2D grid instead of list
 Draw attention to patient information
▪ Taieb-Maimon et al. : recognition increased
from 7% to 43% with photo
 Use decision support system
Poor verification,
less error recognition



Use visual summary of patient history
Avoid visual distraction
Re-enter ID
▪Human Error Classification
▪Attention Theory
▪Context Recovery Process
▪Cognitive Task Analysis
▪User Interface Design Principles
▪Expert Feedback
▪Medical Literature

Categorization of the error-types, and sources

Suggestions of User Interface remedies

Prototype demonstrating the techniques

Small changes in the UI can make
big difference in patient safety

Include Clinicians and HCI
researchers in the design process

To err is human, the systems
should make up for it
www.cs.umd.edu/hcil/WPE
www.youtube.com/watch?v=CrwOJIrnsg8
Awalin Sopan, Catherine Plaisant,
Seth Powsner, Ben Shneiderman
@awalinsopan
awalin@cs.umd.edu
We thank the Patient-Centered Cognitive Support under the
Strategic Health IT Advanced Research Projects Program
(SHARP) from the Office of the National Coordinator for
Health Information Technology (Grant No. 10510592).