'Human error' blamed for €3.6bn mistake

RTE News Ireland 2 November 2011

Minister for Finance Michael Noonan has said the mistake in the national accounts of €3.6bn was down to "human error". He explained in the Dáil that the double count arose because the Housing Finance Agency had borrowed directly from the NTMA instead of from the open market in 2010.

The miscalculation was described as "a humiliating schoolboy error".

Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records

Pulished in draft from the National Institute of Standard and Technology September 2011

The report summarises the rationale for Usability Protocol for an Electronic Health Record (EHR) that encompasses procedures for (1) expert evaluation of an EHR user interface from a clinical perspective and a human factors best practices perspective, and (2) validation studies of EHR user interfaces with representative user groups on realistic EHR tasks.


Examples of usability issues that have been reported by health care workers are include:
• Some EHR workflows do not match clinical processes create inefficiencies,
• Poorly designed EHR screens slow down the user and sometimes endanger patients,
• Large numbers of files containing historical patient information are difficult to search, navigate, read efficiently, and identify trends over time,
• Warning and error messages are confusing and often conflicting
• Alert fatigue (both visual and audio) from too many messages leading to users ignoring potentially critical messages, and
• Frustration with what is perceived as excessive EHR user interaction (mouse clicks, cursor movements, keystrokes, etc.) during frequent tasks.

A three step process is proposed for the design and evaluation of EHR as follows:

Step One: During the design of an EHR, the development team incorporates the users, work settings and common workflow into the design. Two major goals for this step that should be documented to facilitate Steps Two and Three are: (a) a list of possible medical errors associated with the system usability, and (b) a working model of the design with the usability that pertains to potential safety risks.

Step Two: The Expert Review/Analysis of the EHR step compares the EHR’s user interface design to scientific design principles and standards, identifies possible risks for error and identifies the impact of the design of the EHR on efficiency. This review/analysis can be conducted by a combination of the vendor’s development team and/or by a dedicated team of clinical safety and usability experts. The goals of this step are: (a) to identify possible safety risks and (b) identify areas for improved efficiency.

Step Three: The Testing with Users Step examines the critical tasks identified in the previous steps with actual users. Performance is examined by recording objective data (measured times such as successful task completion, errors, corrected errors, failures to complete, etc.) and subjective data (what users identify). The goals of this step are to: (a) make sure the critical usability issues that may potentially impact safety are no longer present and (b) make sure there are no critical barriers to decrease efficiency. This is accomplished through vendor-evaluator team review meetings where vendor’s system development and evaluation teams examine and agree that the design has (a) decreased the potential for medical errors to desired levels and (b) increased overall use efficiency due to critical usability issues.

Current training programs may not prepare firefighters to combat stress

Medical Xpress 2 November 2011
Article summarises findings from a study by Michael R. Baumann, Carol L. Gohm, and Bryan L. Bonner in an article titled "Phased Training for High-Reliability Occupations: Live-Fire Exercises for Civilian Firefighters,"

The authors assessed the value of current scenario-based training programs and found they may not effectively prepare firefighters for the range of scenarios they are likely to encounter

Firefighters must make complex decisions and predictions and must perform extreme tasks at a moment's notice. Failure to keep a level head in the face of a dangerous situation may result in disastrous consequences. The most common form of training exposes firefighters to one or a very small set of live-fire scenarios designed to reduce stress and encourage calm decision-making skills. But repeated exposure to the same scenario may fail to adequately prepare firefighters for changing situations, as lessons learned in that scenario may not transfer to a different scenario. "If you learn the scenario, you can predict what will happen in that one scenario, but you can't predict what will happen in situations that look a little different," said Baumann. "If you learn general principles, then you can predict what is going to happen in a wide range of situations."

The authors suggest that trainers should increase the range of scenarios to which firefighters are exposed. Desktop-based simulators are available to supplement live-fire training with a variety of scenarios to enable trainees to learn basic principles, even though such simulators cannot replicate a live-fire environment.

The Four Phases of Design Thinking

Harvard Business Review blog by Warren Berger 29 July 2011

A good designer has the ability to bring original ideas into the world. They seem to share the same behaviours:

1. Question - Designers ask, and raise, a lot of questions including "stupid questions" that challenge the existing realities and assumptions. Asking "why" can make the questioner seem naïve while putting others on the defensive but it does require people to question and rethink basic fundamentals.

2. Care - Step out of the corporate bubble and actually immerse yourself in the daily lives of people you're trying to serve. Really observing and paying close attention to people. "Focus groups and questionnaires don't cut it."

3. Connect - Taking existing elements or ideas and mashing them together in fresh new ways. You don't necessarily have to invent from scratch but designers know that you must "think laterally" to connect ideas that might not seem to go together.

4. Commit - It's one thing to dream up original ideas. But designers quickly take those ideas beyond the realm of imagination by giving form to them. There is a risk that committing too early increases the possibility of short-term failure but "designers tend to be much more comfortable with this risk than most of us." Innovation is an iterative process and small failures are actually useful because they show the designer what works and what needs fixing.