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Heuristic (Expert) Evaluation and RCA Improvement

Heuristic (Expert) Evaluation and RCA Improvement . Michigan Health & Safety Coalition – Annual Conference John Gosbee, MD, MS VA National Center for Patient Safety www.patientsafety.gov. Improvements to RCAs. More specific root causes to help guide your actions

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Heuristic (Expert) Evaluation and RCA Improvement

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  1. Heuristic (Expert) Evaluation and RCA Improvement Michigan Health & Safety Coalition – Annual Conference John Gosbee, MD, MS VA National Center for Patient Safety www.patientsafety.gov

  2. Improvements to RCAs • More specific root causes to help guide your actions • More detailed evaluation to work directly with • Companies, so they can change • Existing devices, trouble shooting guides, training… • All future devices of that type or style • Designers and architects • Work area layout and “casework” • Room and building design

  3. Heuristic Evaluations Nielsen, 1994 • Usability specialists assess user interface elements to see how they measure up to known usability heuristics/guidelines • Use set of heuristics like Nielsen’s Top Ten List • Focus on the tasks a user would use object for • Differs from usability testing where user(s) work through a task to simulate actual work with minimal interaction from observer(s) of their interactions

  4. Nielsen’s Top Ten List Adapted from Nielsen (1993) 1. Simple and Natural Dialogue 2. Speak the Users’ Language 3. Minimizing User Memory Load 4 . Consistency 5. Feedback 6. Clearly Marked Exits 7. Prevent Errors • Good Error Messages • Help and Documentation • Readable and understandable labels and warnings

  5. We are focusing on these four areas today • Simple and Natural Dialogue • Consistency • Feedback • Readable and understandable labels and warnings

  6. Three Exercises: • Code cart and oxygen cylinder • From video of “event” • IV Pump interface • From 8x11 pictures • Heuristic Evaluation of MRI suite • From displayed layout

  7. Questions and tools arise from • Human factors design guidelines and principles • PSAT (Patient Safety Assessment Tool) • Summaries & analysis of RCAs in VA database • A combination of above

  8. IV Pump interface • For IV Pump • Three color pictures for each group • HE set of questions • “RCA” style documentation sheet • Not all questions can be answered • For “bonus”, also estimate: • Likely frequency of design issue • Likely severity of design issue

  9. MR Hazards and Safety • MR is always on ($25K to $500K to shut off) • Magnetic field is always invisible • Not all metallic appearing items are ferrro-magnetic • Not all ferro-magnetic items appear metallic Is this sand bag a problem?

  10. MR Safety Video Excerpts • Wrench on chain • Iron-filled tennis ball • Wrench into bricks and Aluminum pail

  11. MR Suite (Amalgam) Magnet Room Control Room Hospital Alcove or Ante-Room MR-Safe Equipment Area

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