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Norman DA. New York, NY: Basic Books; 2002.
Norman, a cognitive psychologist, outlines the elements of effective user-centered design, which include making the inner workings of devices visible, exploiting natural function, controlling relationships, and using constraints successfully. Through both fable and anecdote, Norman illustrates forcing functions and how bad design can exacerbate the consequences of human error. This classic text is a valuable introduction to the role of design in patient safety. [Note: Originally published in 1988 as The Psychology of Everyday Things.]
Journal Article > Study
Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.
Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010;304:2595-2602.
In November 2009, the US Food and Drug Administration (FDA) released a voluntary set of recommendations around the safety of over-the-counter (OTC) medications, particularly for children. This study examined the prevalence of inconsistent dosing directions and measuring devices among 200 top-selling pediatric liquid OTC medications. Investigators discovered an alarming 99% rate of inconsistency between medication dosing directions and the markings on the measuring device. Furthermore, the use of milliliter, teaspoon, and tablespoon units were also highly variable as was nonstandard abbreviations for milliliter. The authors advocate for three specific recommendations based on their findings: (i) ensure standardized measuring devices in all liquid packaging, (ii) ensure consistency between label dosing instructions and markings on measuring devices, and (iii) choose standard measurement units and abbreviations. A related editorial and news piece [see links below] discuss the implications of this study and the growing need for action to promote patient safety. A past AHRQ WebM&M commentary discussed a pediatric dosing error involving OTC acetaminophen.
Journal Article > Study
Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.
Drew BJ, Harris P, Zègre-Hemsey JK, et al. PLoS One. 2014;9:e110274.
Alarm fatigue, in which clinicians ignore safety alerts if they are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation. This concern is particularly acute in intensive care units where patients are typically monitored with multiple devices, each with alarms. This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram, blood pressure, and oxygenation, from five intensive care units in a medical center. The vast majority of alarms were false-positives. Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable events were common causes for unnecessary alarms. The authors call for improving device design and monitor algorithms in order to reduce alarm fatigue. A previous AHRQ WebM&M perspective discussed the safety of medical devices.