Annie’s Story: How a System’s Approach Can Change Safety Culture

In an era dependent on technology to make our lives easier, patients continue to suffer from severe complications with medical devices. While the FDA monitors problems associated with medical devices, some devices require thoughtful design and sufficient research before the devices are rushed to market. As part of the research, such devices require a close look at how they work within a system. Some devices receive the proper research1 after it is made publicly available, when end-users unintentionally go through a trial-and-error phase.

Annie, a nurse at MedStar Health, describes an incident involving a faultily-designed glucometer, where she was by the design error. The glucometer reading showed up as “high” but the patient’s blood sugar was actually the exact opposite. She treated the patient based on the glucometer reading and the patient ended up in the ICU. After being reprimanded for the error, Annie conveys the impact when the “blame and shame” approach is used as opposed to a “just culture.” MedStar Health shifted their attention to the design of the device, and collaborated with a human factors engineering team to fine tune both the device and the system. As a result, the hospital is working toward finding solutions to prevent future harm. The most important outcome is that the patient fully recovered.

Improving patient safety within the health care community is a slow but rewarding effort. While patient safety incidents are multi-faceted, integrating human factors engineering and design processes are beneficial to identify problems, particularly since there are myriad components in a work system. There are a couple of ways in which health care systems can incorporate human factors engineering:

  • Feature a patient safety course for all clinicians and healthcare professionals
    • Preferably a continuing education course, the intention is to provide the viewer with key principles of patient safety and how human factors engineering can be applied to everyday practice.
  • Implement a patient safety improvement project as it relates to human factors engineering.
    • Quality improvement projects are like research, especially when the process at hand is questioned. These projects involve a change in the system, how the change affects the clinician and the patient. Recognizing that clinicians have limited time to devote to an endeavor, a possible solution may involve asking your local college or university for interns to conduct a study focusing on a device safety.

Errors can occur by system failures and it is crucial to adopt patient safety and quality improvement techniques to identify preventable errors. Health care systems cannot miss the opportunity to incorporate human factors engineering in their systems. At the forefront in health care, system changes can move patient safety improvement efforts forward.

1. Science and Research (Medical Devices). Center for Devices and Radiological Health. US Food and Drug Administration, 03 March 2014.  Accessed 27 May 2014.