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Date and time: Location: Description:
Unfortunately, it is often the individual associated with the error who is presumed to be responsible, and error reduction activities (including punishment, blame, or training) are focused on that individual. Centuries of empirical literature in the physical and social sciences, as well as millennia of philosophical writings, indicate that behavior (be it by a particle or a human) is a function of that entity interacting with its context. In other words, the causes of an error or incident cannot be understood without the context in which it occurred. Thus, the typical approach of blaming the care provider as the sole source of error is incomplete, hence misleading. In a hospital, for example, errors may occur due to a combination of several forces, including poorly designed technology, cultural factors, and various preceding events. There might be an incompatibility of the instruments with the hand size of the surgeon; a problem with the physical layout of equipment in the operating room (for example, a need to move a monitor so that the monitor's angle does not distort the data); or a confusion among look-alike drug names, which leads to an incorrect prescription. Usability and human factors professionals already know that design can reduce the potential for error for a specific product. However, to effectively improve human performance and reduce the risk of error, it is necessary to consider more than just the product: it is necessary to identify the contextual factors that affect its use. This presentation describes a means to address such factors. It presents the “Artichoke model,” a practical framework and worksheet for diagnosing the factors that contribute to error, which has been used successfully in the medical field. Real-world examples of factors that induce error, and the application of the Artichoke model to the use of a product, will be discussed. This meeting is jointly sponsored by UPA-DC and HFES-Potomac (Human Factors and Ergonomics Society). Speaker:
She is the editorial advisor to the patient safety series of articles for AAMI’s journal Biomedical Instrumentation and Technology, is on the editorial board of the journal Human Factors and a reviewer for 11 other journals including Medical Care, the Journal of the American Medical Association, and Applied Ergonomics. Dr. Bogner edits a book series on human error and safety, and one on patient safety for Lawrence Erlbaum Associates. She has also edited two books, Human Error in Medicine (1994) and Misadventures in Health Care: Inside Stories (2004). The second edition of Human Error in Medicine will be published by Erlbaum in 2006/2007. Prior to her current position, Dr. Bogner was a senior human factors specialist with the U.S. Food and Drug Administration (FDA), where she addressed human factors issues in medical device use errors. She has also worked as a research psychologist with the Army Research Institute (ARI) on the MANPRINT program to improve the ease of use and safety of Army equipment. Dr. Bogner is a Fellow of the American Psychological Association, the Human Factors and Ergonomics Society, and the Washington Academy of Sciences. She holds a B.S. in Psychology and Mathematics and a Ph.D. in Psychology (Gestalt). Registration: After you have registered, we encourage you to pay in advance by using our online PayPal form or mailing a check. Cost: Directions to the Program: By Car: By Metro, Bus or on Foot: Directions to Dinner: Contact the for events-related issues. |
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