This MedStar Health Team is Trying to Engineer Human Error Out of Medicine

Dr. Zach Hettinger, left, simulates a medical procedure. Since Hettinger is wearing eye-tracking technology, scientific director Raj Ratwani can observe the interplay between clinician and technology.

Washington Business Journal. By Tina Reed.

A small group at MedStar Health is searching for ways to engineer the "human factor" — specifically human error — out of medicine.

The MedStar Health National Center for Human Factors in Healthcare, a team of 20 engineers, researchers and cognitive psychologists, say they're taking a page from the safety playbook of industries like aviation and nuclear energy to tackle patient safety. At its core, it's all about how an industry reacts when mistakes happen.

"We're not getting any safer by looking at who was responsible for the error," said Dr. Terry Fairbanks, director of the center. "We need to understand how that error occurred."

Once they do, he said, this group is tasked with designing ways to stop others from making the same mistake again.

A Hard Conversation

Flushed with fever, an 11-month-old girl was rushed to a MedStar Health emergency department earlier this year. She very nearly suffered the impact of a harmful medical misunderstanding.

After a nurse recommended giving the infant 5 milliliters of ibuprofen based on a common dosing form, the baby’s father almost gave the little girl far too much of the medicine because he’d bought commonly available infant drops, a much more concentrated version of the pain killer.

Before he did, the infant’s mother — a MedStar Health associate — realized the nurse’s recommendation had instead been based on the children’s version, a weaker formulation. It was only a close call. But it’s an example of the kind of problems the human factors group has been taking on, whether it be a potential for patient misunderstanding or outright errors made by a medical professional.

This is not easy for health care providers to talk about. Medical personnel are supposed to have the answers to help people. They aren't supposed to make mistakes that would harm them. But studies have shown this is a crucial issue to tackle: A 2013 study published in the Journal of Patient Safety found more than 400,000 people are killed every year and far more are seriously injured. "The epidemic of patient harm in hospitals must be taken more seriously," its authors concluded.