It’s like having 10 different remote controls for 10 different TVs

This NPR interview with Danielle Ofri, author of a new book on medical errors (and their prevention), had some interesting insight into how human factors play out during a pandemic. Her new book is “When We Do Harm,” and I was most interested in these excerpts from the interview: “…we got many donated ventilators. Many … Continue reading It’s like having 10 different remote controls for 10 different TVs

This NPR interview with Danielle Ofri, author of a new book on medical errors (and their prevention), had some interesting insight into how human factors play out during a pandemic.

Her new book is “When We Do Harm,” and I was most interested in these excerpts from the interview:

“…we got many donated ventilators. Many hospitals got that, and we needed them. … But it’s like having 10 different remote controls for 10 different TVs. It takes some time to figure that out. And we definitely saw things go wrong as people struggled to figure out how this remote control works from that one.”

“We had many patients being transferred from overloaded hospitals. And when patients come in a batch of 10 or 20, 30, 40, it is really a setup for things going wrong. So you have to be extremely careful in keeping the patients distinguished. We have to have a system set up to accept the transfers … [and] take the time to carefully sort patients out, especially if every patient comes with the same diagnosis, it is easy to mix patients up.”

And my favorite, even though it isn’t necessarily COVID-19 related:

“For example, … [with] a patient with diabetes … it won’t let me just put “diabetes.” It has to pick out one of the 50 possible variations of on- or off- insulin — with kidney problems, with neurologic problems and to what degree, in what stage — which are important, but I know that it’s there for billing. And each time I’m about to write about it, these 25 different things pop up and I have to address them right now. But of course, I’m not thinking about the billing diagnosis. I want to think about the diabetes. But this gets in the way of my train of thought. And it distracts me. And so I lose what I’m doing if I have to attend to these many things. And that’s really kind of the theme of medical records in the electronic form is that they’re made to be simple for billing and they’re not as logical, or they don’t think in the same logical way that clinicians do.”

Third Edition of Designing for Older Adults

The third edition of the definitive source for information for designing for older adults has been published: This new edition provides easily accessible and usable guidelines for practitioners in the design community for older adults. It includes an updated overview of the demographic characteristics of older adult populations and the scientific knowledge base of the … Continue reading Third Edition of Designing for Older Adults

The third edition of the definitive source for information for designing for older adults has been published:

This new edition provides easily accessible and usable guidelines for practitioners in the design community for older adults. It includes an updated overview of the demographic characteristics of older adult populations and the scientific knowledge base of the aging process relevant to design. New chapters include Existing and Emerging Technologies, Work and Volunteering, Social Engagement, and Leisure Activities. Also included is basic information on user-centered design and specific recommendations for conducting research with older adults. 

A 20% discount is available by using code ‘A004‘ at checkout from CRC Press.

The group of authors (the Center for Research and Education on Technology Enhancement) is also running a workshop:

The focus of this workshop is to bring together representatives from companies, organizations, universities, large and small, who are involved in industry, product development, or research who have an interest in meeting the needs of older adults. Additionally, members of the CREATE team will present guidelines and best practices for designing for older adults. Topics include; Existing & Emerging Technologies, Usability Protocols, Interface & Instructional Design, Technology in Social Engagement, Living Environments, Healthcare, Transportation, Leisure, and Work. Each participant will receive a complimentary copy of our book Designing for Older Adults.

If you would like a registration form or any further information on the conference accommodations, please contact Adrienne Jaret at: adj2012@med.cornell.edu or by phone at (646) 962-7153.

Hawaii False Alarm: The story that keeps on giving

Right after the Hawaii false nuclear alarm, I posted about how the user interface seemed to contribute to the error. At the time, sources were reporting it as a “dropdown” menu. Well, that wasn’t exactly true, but in the last few weeks it’s become clear that truth is stranger than fiction. Here is a run-down … Continue reading Hawaii False Alarm: The story that keeps on giving

The post Hawaii False Alarm: The story that keeps on giving first appeared on the Human Factors Blog.

Right after the Hawaii false nuclear alarm, I posted about how the user interface seemed to contribute to the error. At the time, sources were reporting it as a “dropdown” menu. Well, that wasn’t exactly true, but in the last few weeks it’s become clear that truth is stranger than fiction. Here is a run-down of the news on the story (spoiler, every step is a human factors-related issue):

  • Hawaii nuclear attack alarms are sounded, also sending alerts to cell phones across the state
  • Alarm is noted as false and the state struggles to get that message out to the panicked public
  • Error is blamed on a confusing drop-down interface: “From a drop-down menu on a computer program, he saw two options: “Test missile alert” and “Missile alert.”
  • The actual interface is found and shown – rather than a drop-down menu it’s just closely clustered links on a 1990s-era website-looking interface that say “DRILL-PACOM(CDW)-STATE ONLY” and “PACOM(CDW)-STATE ONLY”
  • It comes to light that part of the reason the wrong alert stood for 38 minutes was because the Governor didn’t remember his twitter login and password
  • Latest news: the employee who sounded the alarm says it wasn’t an error, he heard this was “not a drill” and acted accordingly to trigger the real alarm

The now-fired employee has spoken up, saying he was sure of his actions and “did what I was trained to do.” When asked what he’d do differently, he said “nothing,” because everything he saw and heard at the time made him think this was not a drill. His firing is clearly an attempt by Hawaii to get rid of a ‘bad apple.’ Problem solved?

It seems like a good time for my favorite reminder from Sidney Dekker’s book, “The Field Guide to Human Error Investigations” (abridged):

To protect safe systems from the vagaries of human behavior, recommendations typically propose to:

    • Tighten procedures and close regulatory gaps. This reduces the bandwidth in which people operate. It leaves less room for error.
    • Introduce more technology to monitor or replace human work. If machines do the work, then humans can no longer make errors doing it. And if machines monitor human work, they ca
    snuff out any erratic human behavior.
    • Make sure that defective practitioners (the bad apples) do not contribute to system breakdown again. Put them on “administrative leave”; demote them to a lower status; educate or pressure them to behave better next time; instill some fear in them and their peers by taking them to court or reprimanding them.

In this view of human error, investigations can safely conclude with the label “human error”—by whatever name (for example: ignoring a warning light, violating a procedure). Such a conclusion and its implications supposedly get to the causes of system failure.

AN ILLUSION OF PROGRESS ON SAFETY
The shortcomings of the bad apple theory are severe and deep. Progress on safety based on this view is often a short-lived illusion. For example, focusing on individual failures does not take away the underlying problem. Removing “defective” practitioners (throwing out the bad apples) fails to remove the potential for the errors they made.

…[T]rying to change your people by setting examples, or changing the make-up of your operational workforce by removing bad apples, has little long-term effect if the basic conditions that people work under are left unamended.

A ‘bad apple’ is often just a scapegoat that makes people feel better by giving a focus for blame. Real improvements and safety happen by improving the system, not by getting rid of employees who were forced to work within a problematic system.

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‘Mom, are we going to die today? Why won’t you answer me?’ – False Nuclear Alarm in Hawaii Due to User Interface

Image from the New York Times The morning of January 13th, people in Hawaii received a false alarm that the island was under nuclear attack. One of the messages people received was via cell phones and it said:“BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” Today, the Washington Post … Continue reading ‘Mom, are we going to die today? Why won’t you answer me?’ – False Nuclear Alarm in Hawaii Due to User Interface

The post ‘Mom, are we going to die today? Why won’t you answer me?’ – False Nuclear Alarm in Hawaii Due to User Interface first appeared on the Human Factors Blog.


Image from the New York Times

The morning of January 13th, people in Hawaii received a false alarm that the island was under nuclear attack. One of the messages people received was via cell phones and it said:“BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” Today, the Washington Post reported that the alarm was due to an employee pushing the “wrong button” when trying to test the nuclear alarm system.

The quote in the title of this post is from another Washington Post article where people experiencing the alarm were interviewed.

To sum up the issue, the alarm is triggered by choosing an option in a drop down menu, which had options for “Test missile alert” and “Missile alert.” The employee chose the wrong dropdown and, once chosen, the system had no way to reverse the alarm.

A nuclear alarm system should be subjected to particularly high usability requirements, but this system didn’t even conform to Nielson’s 10 heuristics. It violates:

  • User control and freedom: Users often choose system functions by mistake and will need a clearly marked “emergency exit” to leave the unwanted state without having to go through an extended dialogue. Support undo and redo.
  • Visibility of system status: The system should always keep users informed about what is going on, through appropriate feedback within reasonable time.
  • Error prevention: Even better than good error messages is a careful design which prevents a problem from occurring in the first place. Either eliminate error-prone conditions or check for them and present users with a confirmation option before they commit to the action.
  • Help users recognize, diagnose, and recover from errors: Error messages should be expressed in plain language (no codes), precisely indicate the problem, and constructively suggest a solution.
  • And those are just the ones I could identify from reading the Washington Post article! Perhaps a human factors analysis will become regulated for these systems as it has been for the FDA and medical devices.

    The post ‘Mom, are we going to die today? Why won’t you answer me?’ – False Nuclear Alarm in Hawaii Due to User Interface first appeared on the Human Factors Blog.