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      Patient safety and interactive medical devices: Realigning work as imagined and work as done

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          Abstract

          Medical devices are essential tools for modern healthcare delivery. However, significant issues can arise if medical devices are designed for ‘work as imagined’ when this is misaligned with ‘work as done’. This problem can be compounded as the details of device design, in terms of usability and the way a device supports or changes working practices, often receives limited attention. The ways devices are designed and used affect patient safety and quality of care: inappropriate design can provoke user error, create system vulnerabilities and divert attention from other aspects of patient care. Current regulation involves a series of pre-market checks relating to device usability, but this assumes that devices are always used under the conditions and for the purposes intended (i.e. work as imagined); there are many reasons for devices being used in ways other than those assumed at development time. Greater attention needs to be paid to learning points in actual use and user experience (i.e. work as done). This needs to inform manufacturers’ designs, management procurement decisions and local decisions about how devices are used in practice to achieve co-adaptation; without these, we foster risks and inefficiencies in healthcare.

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          Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.

          The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors--the least likely medication error to be intercepted--these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.
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            Hazards with medical devices: the role of design.

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              Understanding infusion administration in the ICU through Distributed Cognition.

              To understand how healthcare technologies are used in practice and evaluate them, researchers have argued for adopting the theoretical framework of Distributed Cognition (DC). This paper describes the methods and results of a study in which a DC methodology, Distributed Cognition for Teamwork (DiCoT), was applied to study the use of infusion pumps by nurses in an Intensive Care Unit (ICU). Data was gathered through ethnographic observations and interviews. Data analysis consisted of constructing the representational models of DiCoT, focusing on information flows, physical layouts, social structures and artefacts. The findings show that there is significant distribution of cognition in the ICU: socially, among nurses; physically, through the material environment; and through technological artefacts. The DiCoT methodology facilitated the identification of potential improvements that could increase the safety and efficiency of nurses' interactions with infusion technology.
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                Author and article information

                Journal
                Clin Risk
                Clin Risk
                CRI
                spcri
                Clinical Risk
                SAGE Publications (Sage UK: London, England )
                1356-2622
                1758-1028
                September 2014
                September 2014
                : 20
                : 5
                : 107-110
                Affiliations
                [1-1356262214556550]UCL Interaction Centre, University College London, London, UK
                Author notes
                [*]Ann Blandford, UCL Interaction Centre, University College London, Gower Street, London WC1E 6BT, UK. Email: A.Blandford@ 123456ucl.ac.uk
                Article
                10.1177_1356262214556550
                10.1177/1356262214556550
                4361486
                25866466
                a464713b-92ee-4436-b555-b11ecd25dfc4
                © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License ( http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page( http://www.uk.sagepub.com/aboutus/openaccess.htm).

                History
                Categories
                Original Articles

                Medicine
                medical device,patient safety,workarounds,usability,human error
                Medicine
                medical device, patient safety, workarounds, usability, human error

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