We will be presenting our research at the Human-Computer Interaction conference (4-8 July 2011) and at the European Workshop on Dependable Computing workshop (11-12 May 2011).
The following abstracts have been accepted as ‘long papers’ at HCI 2011.
Unremarkable errors: low-level disturbances in infusion pump use.
Dominic Furniss (UCLIC), Ann Blandford (UCLIC) and Astrid Mayer (Royal Free)
Abstract: In this paper we describe results from an exploratory study observing infusion pump use in practice. From 31 observations of pump programming we note 10 low-level disturbances, which we conceptualise in terms of unremarkable error. This data supports a view that well performing systems cope with error as part of their normal work. Users are able to recover from error and are resilient to performance deviations. However, it is not clear how we, as HCI researchers, should respond to these minor errors: should we aim to minimise them or instead aim to improve detection, recovery and control in safety-critical systems? What is clear is that without remarking on unremarkable error we cannot begin this dialogue and consider the handling of these issues. To conclude we recognise four important factors that influence remedial action, and we highlight the need for a socio-technical approach for making change that is appropriate for practice.
Sarah Wiseman (UCLIC), Paul Cairns (University of York) and Anna Cox (UCLIC)
Abstract: People are prone to errors in many aspects of life, including when entering numbers. The effects of these errors can be disastrous, for example when an incorrect number is entered when programming a medical infusion pump or when entering financial information into a system. Designing better systems may help to prevent these errors however, in order to do this we need to understand far more about the types of errors being made, and their causes. Unfortunately, there are very few documented examples of number entry errors and thus many of the studies conducted so far rely upon modelled, not real world data. This paper reports a study that was designed to elicit number entry errors and the subsequent process of creating a taxonomy of errors from the information gathered. A total of 350 errors were gathered. A method for classifying the errors using 21 codes is proposed — this is a significantly higher figure than previously suggested, showing that currently we underestimate the true number of such errors. These codes are then organised into a taxonomy similar to that of Zhang et al (2004). We show how this taxonomy can be used to guide future research into number entry errors by suggesting experimental conditions needed to provoke certain errors. The taxonomy may also be used during the initial stages of design to help the designer understand the categories of errors that users are most likely to make and thus design accordingly.
The following abstract has been accepted as a long paper at Resilience Engineering 4th Symposium.
Resilience in an Oncology Day Care Unit: Unwritten rules for safety and performance
Dominic Furniss, Jonathan Back and Ann Blandford (UCLIC)
Abstract: Our intention at the outset of this observational study was to understand the interaction design issues associated with infusion pumps in an Oncology Day Care Unit. Here, infusion pumps are widely used for intravenous treatments e.g. chemotherapy. It quickly became apparent that too much of a focus on the pump’s interaction missed important issues that influence the potential for error in the system. More broadly this shows how a traditional HCI (Human-Computer Interaction) perspective can benefit from a broader analysis in terms of resilience. In this paper we use the Resilience Markers Framework (Furniss et al., 2011) to see if its structure and concepts provide utility in describing resilience mechanisms and features in medical practice. It was originally developed to analyse resilient behaviour in nuclear power plant control room scenarios but it has not yet been extended to other domains.
Towards a formal framework for reasoning about the resilience of dynamic interactive systems
Paolo Masci, Paul Curzon, Huayi Huang, Rimvydas Rukš??nas (QMUL; Ann Blandford, Dominic Furniss and Atish Rajkomar (UCLIC)
We propose a conceptual framework for integrating four different approaches for reasoning about interactive systems design: DiCoT, HUM, Resource Model, Device Model. The framework draws ideas from formal analysis of distributed systems and automated synthesis of resilient systems.
The workshop paper has been accepted at EICS4Med.
The visible and the invisible: Distributed Cognition for medical devices
Dominic Furniss, Ann Blandford (UCLIC); Astrid Mayer (Royal Free); Atish Rajkomar and Chris Vincent (UCLIC)
Abstract: Many interactive medical devices are less easy to use than they might be, and do not fit as well as they could in their contexts of use. Occasionally, the deficiencies lead to serious incidents; more often, they have a less visible effect on the resilience and efficiency of healthcare systems. These issues remain largely invisible as they are not reported and have rarely been studied. In this paper, we report on the use of DiCoT as an approach to representing and reasoning about medical work, and about the role of device design within that work. We focus in particular on the design and use of infusion devices. This work highlights the value of observational studies for engineering interactive medical devices, and illustrates the value of a systematic approach to gathering and analyzing qualitative data.
On formalising interactive number entry on infusion pumps
sci, Rimvydas Rukš??nas, Paul Curzon, Patrick Oladimeji (QMUL); Abigail Cauchi, Yunqiu Li and Harold Thimbleby (Swansea)
We explore the notion of predictability of a user interface in the situation where the user is an expert and understands perfectly how the device works. We formalise the interface of the Alaris and of the BBraun infusion pumps, and show that the interface of the BBraun is not predictable in certain situations. Modelling distributed cognition systems in PVS
Paolo Masci, Paul Curzon (QMUL); Ann Blandford and Dominic Furniss (UCLIC)
It describes a set of generic theories to model information flow in complex interactive systems. A case study based on the London Ambulance Service is modelled and analysed. Results highlight hidden assumptions in the procedure, and flaws in users’ mental model of the system. The following has been submitted to EICS4Med.
Comparing actual practice and user manuals: a case study based on programmable infusion pumps
Paolo Masci, Paul Curzon, Huayi Huang, Rimvydas Rukš??nas (QMUL); Abigail Cauchi, Parisa Eslambolchilar, Andy Gimblett, Yunqiu Li, Patrick Oladimeji, Harold Thimbleby (Swansea University); Michael Harrison (University of Newcastle); Ann Blandford, Dominic Furniss, Atish Rajkomar (UCLIC); Paul Lee (Singleton Hospital, Swansea)
Precise description of work practice and manual of infusion procedure with BBraun infusion pump. Analysis points out how minor mismatches between the two descriptions can be used to reveal major safety issues.
We’ve submitted a short paper to Interact 2011
Number Entry Interfaces and their Effects on Error
Patrick Oladimeji, Harold Thimbleby (Swansea) and Ann Cox (UCLIC)
Abstract: A significant amount of interaction involves number entry. The purpose of any number entry interface is to accurately select or set a numeric value. There are two main styles of number entry interfaces found on medical devices: serial interfaces like the ubiquitous 12-key numeric keypad, and incremental interfaces that use a knob or a pair of keys to increase or decrease numbers. We report an experiment that investigates the effect of interface design on error detection in number entry. The initial findings show that the incremental interface produces more accurate inputs than the serial interface, and the magnitude of errors suggests that the incremental interface could reduce the death rate relative to the numeric keypad.