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Thousands die because of poorly designed technology, author says: Ill-conceived systems blamed for 'human error'

By Dan Lazin

Originally appeared in the Edmonton Journal

A blinking VCR clock is trivial when compared with at least 5,000 needless deaths in Canadian hospitals every year.

But the two problems are linked by the bad fit between technology and those who use it, says the author of a new book on the subject. What most people call "human error" is really the fault of bad design, says University of Toronto engineering professor Kim Vicente, who wrote The Human Factor.

"People feel, 'Well, I'm stupid. I'm technologically illiterate.' What we see repeatedly is just the opposite," he said.

Bad design is widespread, he said — and only amazing human adaptability gets people through.

Between 5,000 and 11,000 Canadians die each year because of preventable medical errors caused by bad design, Vicente estimates. Those deaths could be prevented if the health-care system respected both practitioners and patients as real people, Vicente said Wednesday in Edmonton.

"I think a lot of people in society feel alienated because of this technological change and the pace of technological change."

Those people include not just consumers struggling to program clocks, but airline pilots, nuclear control-room operators, doctors and nurses.

(His definition of technology is broad, including even organizational systems such as health care, a workplace hierarchy or government itself.)

Some industries, such as aviation, have adapted well, using techniques like thoughtful organization of a cockpit to help prevent crashes. Health care has a longer way to come.

On the high-tech side, he said one machine that administers painkillers is so complicated at least 65 people worldwide — maybe as many as 667 — have died from bad programming.

On the low-tech side, he said the threat of lawsuits keeps doctors and nurses from reporting mistakes in treatment that the whole system could learn from.

Vicente tells of a U.S. Veterans Administration hospital that took a compassionate stance, telling patients and families every time the hospital made a mistake, even helping them sue. Lawsuits ended up costing less because the patients had no desire for revenge. At the same time, the hospital was better able to see and learn from mistakes.

"I've talked to people in health care and they're amazed that any hospital can operate this way," he said. "It's so contrary to the standard tell-nothing, admit-nothing process."

Similarly innovative solutions in Canadian health care will likely have to wait until a report is completed on "adverse events" in Canadian hospitals.

That report is due out in December or January, said one of the primary researchers, U of T medical professor Ross Baker.

When the report comes out, Vicente said, patient safety will become a major issue.

Hospitals will then be under more pressure to make sure the machines they buy are easy to use. Because doctors and nurses can make mistakes, the system must cater to them.

One low-tech way for patients to improve the system, he said, is to ask three simple questions when a doctor prescribes drugs: What is my name? What are you giving me? How much are you giving me?

If patients asked those questions, "We would see a drastic reduction in medication errors," he said.

"It admits that the patient is part of the health-care system rather than an external object that is treated by the health-care system. That's a big shift."