People + Process = Performance

NEVER AGAIN: The Role of Human Factors/Ergonomics in Design For Preventing “Never Events”

Have you ever had an experience with a product or a machine in which you said to yourself, “This is a poor design”?  Or, have you ever walked into a space (office, store, restaurant, etc.) find yourself saying, “Why is this here and not over there?” or “What were they thinking (when they designed this)”?

Those scenarios are based on the design of a product or a space.  What about a system or process?  Have you ever been in a meeting in which your boss outlined a new process for doing “x” and you thought that that doesn’t make sense?  Or, have you been a part of a process improvement project or incident investigation in which the root cause of the problem was determined to be “human error”?

If so, you’ve experienced ‘design’—mostly likely non-optimal or poor design.  Here are the common definitions of design: (source:  www.thefreedictionary.com)

  • a sketch or drawing or graphic representation
  • to formulate a plan for
  • a plan or a project
  • A basic scheme or pattern that affects and controls function or development

As a human factors specialist/ergonomist I find myself focusing on design in almost everything I do.  To me, design covers not only the physical layout of a space and the machines, furniture and equipment within that space but also the processes going on within the same and the overall culture and environment.  Why do I focus on design, because design, whether of products, places, environments and systems, has an effect on human behavior and performance.  Design therefore plays a significant role in preventing or causing injuries, errors, defects and poor performance.  One needs to understand and appreciate the important role that design has in regards minimizing/eliminating the unwanted outcomes and risks.

A simple example relates to my passion of food and cooking.  Because of this I am always looking for the next pot, gadget or pan that I should add to my kitchen arsenal.  My latest addition  was a pressure cooker.  However, given my HF/E background and concern with design I did a lot of research on pressure cookers before purchasing the one.  I did that because I knew that a poorly designed pressure cooker could result in a bad outcome.  I also know that an inexperienced pressure cooker user (myself) could also achieve a bad outcome if she didn’t follow the directions correctly!  So I purposely looked for one that was of high quality material, had easy to read pressure gauge and controls, and clear step-by-step instructions on how to use properly.  Why?  Because I don’t want to cause damage to my kitchen or myself!

In healthcare there are certain ‘events’ that are highly desired to be avoided.  These events are called “Never Events”.  A Never Event was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The list is grouped into six categorical events: surgical, product or device, patient protection, care management, environmental, and criminal.  (Source: Agency for Healthcare and Quality).

One can take the meaning of never events and apply it to industries and situations outside of healthcare.  It would be reasonable to assume that most companies want to avoid employee and customer injuries.  They want to prevent errors and defects in their processes or products.  And they want avoid wasted time by their employees or downtime by their IT business system.  These events could be classified as “Never Events” as they would be clearly

identifiable and measurable, serious and usually preventable.  Most, if not all of those events, are impacted by humans in some way by their behavior, performance and physical abilities.

In my upcoming blogs, I’ll be exploring how incorporating human factors and ergonomics in design can and should have a significant impact in preventing “Never Events”.