Ergonomics is about matching the environment to the human. Many times we focus on a narrow environment such as a chair, desk, or assembly line. This thinking can be broadened to include whole environments like an off shore oil rig, or a hospital operating room. This broadened approach to looking at ergonomics is sometimes known as a systems approach, or macro-ergonomics.
It is through this broad scope of matching the environment to known human capabilities and limitations that the newly created San Diego Center for Patient Safety (SDCPS) hopes to improve patient safety and reduce the occurrence and severity of medical errors.
To accomplish this, the SDCPS has established a joint effort between the Veterans Affairs (VA) San Diego Healthcare System and University of California, San Diego Health Sciences. The efforts are funded by a three-year, $590,000 grant by the Agency for Healthcare Research and Quality (AHRQ). The SDCPS is directed by Matthew B. Weinger, M.D. Dr. Weinger is a Professor of Anesthesiology at the UCSD School of Medicine, and also Director of the Anesthesia Ergonomics Research Laboratory at the VASDHS.
Weinger has stated that the SDCPS’ activities will promote the concept that clinical care providers can and should create safety. This is in contrast to the view that safety issues arise because clinicians make errors.
To give an example, assume there are two switches side by side at the foot of a patient’s bed. These switches are the same size, shape, and color but are used to administer two very different medications. In a high stress situation what is the risk that the incorrect medication would be administered? Does the design of the system (switches) lend to making a mistake or preventing a mistake. If the switches were different sizes or shapes, or on opposite sides of the bed, could an error be avoided? These are the types of questions that a macro-ergonomics approach to a design or analysis tries to answer.
Another factor of particular interest to SDCPS is the role of communication – between the clinician and patient, and between clinicians – in diagnosis and treatment. According to SDCPS, previous studies have shown that communication failure is a contributor to medical errors, and in a diverse community like San Diego, with language and cultural influences coming into play, the risk of error and injury increases.
SDCPS is part of a wider effort by both the VA San Diego Healthcare System and UCSD Health Sciences to improve patient safety. Weinger recently received more than $1 million in new grant support to study unexpected clinical events during anesthesia and surgery.