What do the Chernobyl nuclear disaster and the painting of flies on men's urinals have in common? According to Kim Vicente, both are examples of the way in which technology and people interact to create more or less desirable outcomes.
Figure 1.
Kim Vicente
Routledge, $27.95, pp 352 ISBN 0 415 97064 4 www.routledge-ny.com
Rating: ★★★★
In the case of Chernobyl, the designers of the nuclear power plant developed a technology that outstripped the ability of the operators to use it safely. The tragic consequence was an explosion that resulted in death or serious illness to thousands of people, with reverberations around the world.
By contrast, the strategic location of painted flies on men's urinals minimised the risk of “splash back” by making it easy for the users to do what comes naturally. In this case, the technology in question (the painted flies) appealed to the desire of men to aim in a direction that avoided an adverse outcome (trouser stains).
Both examples illustrate the need for technology to be designed in a way that takes account of human capability and fallibility. Nowhere is this need greater than in health care. Ever since the Harvard medical practice study (New England Journal of Medicine 1991;324: 370-6, 377-841987460) estimated that there were between 44 000 and 98 000 preventable deaths each year in US hospitals, the issue of patient safety has risen up the health policy agenda.
In the process, there has been increasing recognition that most medical errors are not the result of individual failings. Rather, healthcare professionals make mistakes because humans are fallible, and because they use technologies that sometimes increase the risk of error. The argument of this book is that these mistakes will only be avoided through systems thinking.
Vicente shows how aviation has developed systems that have resulted in demonstrable improvements in safety for air travellers. These systems include reporting arrangements that promote learning from near misses, and training programmes that enable aircraft crews to work effectively as teams. The design of cockpit instruments has also improved with simple changes in layout and materials helping to reduce errors and promote safety.
Belatedly, some of the lessons from aviation are being applied in health care, although there is a way to go before the same levels of safety are achieved. The obstacles to health care becoming as safe as air travel include the fear of legal liability if mistakes are reported more openly, and a culture in which doctors are trained to believe themselves to be infallible. These obstacles are being overcome through a combination of government action, initiatives from within the health professions, and pressure for reform from an increasingly critical and demanding public.
Figure 2.
Chernobyl: lessons for patient safety
Credit: AP
Vicente argues that further progress depends on bringing together the human sciences and the technical sciences. In essence, he proposes nothing less than a human-tech revolution, a new world view on a par with the Copernican revolution in astronomy, the Darwinian revolution in biology, and the Einsteinian revolution in physics. If this does not happen, then the prospect is of more nuclear power plant meltdowns, more environmental disasters, and more medical errors.
At the heart of the human-tech revolution is the need to tailor technology to human nature. Put simply, it means taking control of technology away from the so-called “wizards,” who are technical experts but who may be blind to the way in which people use technology. Issues of technology design need to be considered alongside psychological limitations, team dynamics, and organisational cultures if the full potential of technology is to be realised.
Many of these arguments have been rehearsed in the field of health care by Lucian Leape, Don Berwick, and others. They are also finding favour in the health policy community, for example through the work of the Institute of Medicine in the United States and the recent focus on patient safety in the NHS. The power of The Human Factor is therefore less in its originality than in its accessibility and its ability to transcend sectors like aviation and health care to distil the principles that must inform future activity.
These principles include behaviour shaping constraints such as anaesthesia machines that make it physically impossible to connect a gas hose to the wrong nozzle; shape coding that makes it easy for people to distinguish between controls that do different things; incident reporting systems that encourage organisational learning; and training systems that promote team working and safety improvements.
The principles outlined in this book are intended to harness technology to better serve human purposes, rather than requiring people to become super human users of complex technology. Anyone who has struggled to master a mobile phone, VCR player, or everyday software package can only endorse this plea. It is to be hoped that those designing the new information technology system for the NHS will also heed the important messages of this book.