Friday, February 28, 2014

Thinking, fast and slow

BBC Horizon 'How do we really make decisions?'  originally aired on BBC 2 on 24 February 2014

Referred to a lot from the book by Daniel Kahneman 'Thinking, fast and slow.'

Most of the time, our fast, intuitive mind is in control, efficiently taking charge of all the thousands of decisions we make each day. The problem comes when we allow our fast, intuitive system to make decisions that we really should pass over to our slow, logical system. This is where the mistakes creep in.

Our thinking is riddled with systematic mistakes known to psychologists as cognitive biases. And they affect everything we do. They make us spend impulsively, be overly influenced by what other people think. They affect our beliefs, our opinions, and our decisions, and we have no idea it is happening.

It may seem hard to believe, but that's because your logical, slow mind is a master at inventing a cover story. Most of the beliefs or opinions you have come from an automatic response. But then your logical mind invents a reason why you think or believe something.
A useful list of Cognitive Biases is available at Wikipedia

Friday, February 14, 2014

Expert witnesses

Notes from a presentation by Alex Sandland of Dyne Solicitors Limited

An expert is:

* Suitably qualified - possessing suitable profession qualifications
* Suitable experienced - possessing suitable professional experience
* Scale and extent of qualifications/experience is proportionate to the scale and seriousness of the dispute
* Independent - have to pass the test 'would they give the same opinion if instructed by the other party?'

In legal proceedings opinions are inadmissible and witnesses must only present facts.  However, an expert is able to state opinion proceedings (provided they fall within their particular area of expertise). 

An experts duty is to the court ONLY.  They cannot promote the case of the instructing party.

A Protocol for the Instruction of Experts to give evidence in civil claims has been published by the civil justice council.

There are a number of associations/registers including:

* The Expert Witness
* Expert Witness Institute
* Directory of Expert Witnesses

A number of organisations offer professional courses, including the Law Society

The criteria used to choose an expert usually include letters after name, years of experience, papers written, standing within the profession (are you approached by people in your industry for advice) and reputation.

Obviously, expert witnesses want to get paid.  It is normal to get an advance fee of 50%, with the remainder paid when the case has been closed.

Thursday, February 13, 2014

Silencing Many Hospital Alarms Leads To Better Health Care

SHOTS by Richard Knox 27 January 2014

Analysis at Boston Medical Center found that 7 North was experiencing 12,000 alarms ­a day, on average. This had led to "alarm fatigue," which occurs when there are so many noises on the unit that it actually desensitizes the staff," says Deborah Whalen, a clinical nurse manager at the Boston hospital. "If you have multiple, multiple alarms going off with varying frequencies, you just don't hear them." 
That can be dangerous. Patients can die when an important alarm is missed, or an electrode on a patient's chest comes unstuck, or a monitor's battery goes dead.

Boston Medical Center hasn't recorded any patient deaths because of alarm failure, but, Whalen says, "we were lucky." A Boston Globe in 2011 found more than 200 deaths nationally related to alarm problems. Last year, the Joint Commission, a national quality-control group, of 98 alarm-related instances of patient harm, including 80 deaths and 13 cases of permanent disability.

The known alarm-related problems are just the tip of an iceberg, according to , the Joint Commission's chief medical officer, because such cases are seriously underreported.

"It is pervasive in almost any accident that occurs in a hospital," McKee says. "If you look carefully, you will most likely find that there was an alarm as a contributing factor."

That's why the Joint Commission has at the top of its current list of issues that hospitals are expected to tackle. McKee says technology has gotten out of control. "We have devices that beep when they are working normally," she says. "We have devices that beep when they're not working."

Boston Medical Center is attracting national attention as a hospital that apparently has conquered alarm fatigue. Its analysis showed the vast majority of so-called "warning" alarms, indicating potential problems with such things as low heart rate, don't need an audible signal. The hospital decided it was safe to switch them off.

The hospital also upgraded some low-level "warning" alarms to a higher level, signifying "crisis" — for instance, a pause in heart rhythm. And nurses were given authority to change alarm settings to account for patients' differences.

"Once that happened," nurse Deborah Whalen says, "many, many, many alarms disappeared. And instead of 90,000 alarms a week, we dropped to 10,000 alarms a week." That's on 7 North alone.

These days you can easily hear how quiet 7 North and all of the adult medical-surgical units at Boston Medical Center have become. Instead of a steady stream of beeps, minutes can pass without an alarm. So when a "crisis" alarm sounds, the staff can easily hear and respond.
"It's a lot more manageable," says staff nurse Amanda Gerety. "It's a lot more pleasant being at work." And when she sleeps, she says with a laugh, "I don't hear alarms in my dreams anymore."

The hospital says patients like it better, too. For one thing, when they press the nurse-call button, the nurses are more likely to hear it.

Rules, Regulations, Policies and Practices (RRPP) - learning from Costa Concordia by Geoffrey Gill 12 March 2013

It is important we learn from the Costa Concordia accident.  But new lessons are unlikely to emerge and it is more likely that the common failure to apply existing Rules, Regulations, Policies and Practices (RRRP) will emerge from the investigation, including the International Safety Management Code and its attendant Safety Management System.
For example, passenger evacuation from the grounded Costa Concordia was impeded and inefficient because passengers had not received muster instruction and guidance within the few hours from boarding until the grounding.  This, despite an informed maritime industry knowing for years that ships generally are at greatest risk from collision, allision, and grounding when close to land, such as when leaving port, than when under way on the open sea. Given this knowledge, one asks why were the conditions on Costa Concordia necessary to trigger the new common sense policy requiring mandatory emergency drills be conducted prior to a passenger vessel departing an embarkation port.

RRPP: the Panacea?
Danger lurks to the extent that new and existing RRPP will be accepted and relied upon as adequate to the risks and, trusting in that reliance, the industry will proceed “business as usual.” But reality is that RRPP are not a panacea capable of remedying risk and human error within the maritime domain, despite politicians’ and regulators’ enthusiasm for reacting to media orchestrated popular concerns as well as even the well-intentioned separate efforts on the part of maritime management.

At least one trade journal has reported existence of a culture of Italian passenger vessels sailing close to shore, a practice of such long standing as to have received the Italian title “inchino.”  Shipboard morale benefitted from close passage off towns where many crew members lived and public relations benefitted from passengers’ enjoyment of the novelty of the experience.  Under such circumstances, credulity is strained when management disavows knowledge of its masters’ participation in the practice. Inchino may present little risk if performed at a safe distance stated in promulgated RRPP.  But existence of such RRPP does not, of itself, ensure adherence.

Given the implied beneficent purposes of inchino, more likely than not, human nature together with cultural and personality factors suggest that over time shipboard justifications would result in the prescribed safe distance observed being progressively decreased and so shrinking the margin of error initially factored into the determination of what distance a safe distance would be and so coming ever closer to land hazards. What initially may have been idiosyncratic behavior becomes shared as more and more sharp end practitioners perceived a benefit from coming closer to the island without experiencing peer or management criticism or punishment.  This type of gradual RRPP erosion is styled “normalization of deviance,” a pernicious undermining of RRPP.

Deliberate violation of RRPP, especially of those that are inartfully worded or are perceived as incompatible with the operational environment, is not infrequent. The violators’ rationales include a misguided desire to advance the company’s economic interests, lack of peer or managerial criticism as well as the personality of the violator. Therefore, RRPP adherence cannot be presumed, even where simulator or audited competence is confirmed.

Even in the absence of violations, there is the potential for violation “coming out of the blue.”  A recent study, where sheep are persons normally disinclined to violate RRPP and wolves have no such scruples, reveals the propensity for RRPP violation:

Sheep in Sheep’s’ Clothing (confirmed non-violators) – 22.5% of respondents, guardians of the standards.

Wolves in Sheep’s’ Clothing – 33.8% of respondents have not yet violated but would violate if circumstances are “appropriate”.

Sheep in Wolves’ Clothing – 14.1% of respondents are violators but not happy violators.

Wolves in Wolves’ Clothing – 29.6% of respondents would not hesitate to violate RRPP.

Strikingly, 77.5% of respondents either reported violating or would have no qualms violating when the opportunity arrives.

The maritime domain is unique in its long tradition of mariners’ recognition and pride in their professional knowledge and competence combined with an environment in which the variety of potential risky circumstances is so extreme that no catechism of RRPP can account for all situations.  The rigidity of RRPP must be balanced against a flexibility that encourages critical thinking and exercise of sound judgment. This necessity is recognized by Rule 2(a) of the COLREGS that, though inartfully worded, allows recourse to “the ordinary practice of seamen or … the special circumstances of the case.” There is real danger that overly detailed and embracive RRPP, however well intentioned, undermine development of necessary judgmental skills. The issue is well stated by a shipmaster quoted as saying:  “… when you are at sea, you have to be able to think, and you can’t [think] when you must slavishly look up [written procedures] in a book.  …  No matter if your own thought is better or not, you have to do what is written.”  Unlike biblical Pharisees bound to the letter of a law, mariners require and deserve reasonable latitude allowing them to accomplish their primary duty of vigilance to protect the lives and material assets entrusted to their keeping.

The challenge that RRPP inhibit critical thinking runs from the sharp end operator upstream to management, where there may be misplaced reliance that RRPP, with little more, satisfies management’s responsibility to ensure a functional Safety Management System. The folly of relying exclusively or excessively upon formal RRPP as providing an appropriate level of safety can be demonstrated from the 2007 sinking in Antarctic waters of the Liberian flagged passenger vessel Explorer, fortunately without casualties. The vessel was in compliance with class requirements for a vessel of her age, type and geographic operating area. However, the classification society and SOLAS rules were unrealistic in view of the harsh Antarctic conditions regularly to be encountered.

Effective RRPP
RRPP innovation is easiest in response to particular past or presently existing situations, where relevant facts are discrete and known. But effective RRPP must address future eventualities to minimize their adverse occurrence and mitigate their consequences if they do occur. A curious and informed mind, willing to explore future possibilities and proactive risk assessment is required for drafting prophylactic RRPP and also a willingness objectively to determine with what response the RRPP are received by those persons intended to apply them and how the RRPP function in practice, i.e. an impact and sustainability assessment.

Remarkable strides have been made, since Titanic’s loss one hundred years ago, in bridge-to-bridge and ship-to-shore (and vice versa) communication, ECDIS, ARPA, AIS, GPS and the like, as well as ship design and construction.  And promulgation of well-intentioned safety oriented RRPP has flourished.
Remaining relatively consistent, however, has been the shipboard authority gradient (despite various incantations of bridge/crew resource management), a degree of nautical daring-do, and organizational competition between protection and profit; the latter no doubt exacerbated by the current challenging economic situation. And while there has developed greater awareness of scene-setting errors and omissions upstream from the front line operator and greater understanding of cognitive limitations, there has been no corresponding advance modifying cognitive limitations of human behavior, such as confirmation and other biases, situational awareness assessment, assimilating information of varying reliability and relevance from multiple sources, dealing with multiculturism and decision making, to name but a few.

When considering what “new” lessons may be learned out of the Costa Concordia casualty, worthy of consideration would be a critical examination of maritime domain RRPP and their limitations and also expanded operator and management education addressing cognitive factors and how those factors influence what occurs on the bridge, in the engine room, and in the boardroom.


Human Centric Design: How Pushback From the FDA Is Driving Innovation

WIRED by Reade Harpham of Battelle Humanic Centric Design 29 January 2014

The following exert from IEC 62366:2007 is being credited with driving improvement "The design of a usable Medical Device is a challenging endeavor, yet many organizations treat it as if it were just “common sense”. The design of the user interface to achieve adequate (safe) Usability requires a very different skill set than that of the technical implementation of that Interface."
– International Standards Organization: IEC:62366:2007, Application of usability engineering to medical devices, pg.6
(see complete standard here).

In the last 36 months medical devices have been tested, re-designed and re-tested with over 2,000 actual users.  These are people off the street, never seen the device before, don’t care how it looks/works/feels users; the people who open a needle, drop it on the dirty bathroom floor, blow it off and inject.
Users, who no matter how much you paid your design firm to develop a great “user experience,” rip open the box; toss the instructions in the trash and get down to business. The unhappy marketing and development teams behind the two-way glass are ever frustrated by how the users used it “wrong,” without really considering the very real possibility they designed “wrong.” Until now…

The FDA is becoming aggressive with their enforcement of good Human Factors, and rightfully so. In 1999, the Institute of Medicine released “to Err is Human,” which outlined the fact that up to 98,000 deaths resulted from medical error at a cost of $29 billion. Since then, they have been steadily beating the drum, releasing new guidance and tirelessly training companies on how to appropriately incorporate human factors. Developers are finally starting to respond, albeit mostly as a result of an application being rejected to lack of human factors.

They are adding “Human Centric Design” line items to their budgets, opening the door for user feedback from the beginning. They are recognizing that a small, well executed usability activity in the early stages of design will save ten times in time and money downstream, not to mention drastically increase the likelihood their device will be approved the first time around.

More importantly, device manufacturers are beginning to recognize the value of a human centric approach from the inception of the idea. Enabling users to have a voice beyond “I prefer this one” can drive design decisions across the entire develo