Abstract

Human error causes perhaps 20,000 “preventable” hospital deaths from adverse events per year in the UK. Computerisation in one form or another is often presented as a solution, however computer systems have the problem that latent errors in design can increase errors yet channel blame from the manufacturer, developers or hospital to the operators at the point of care. Indeed many incident reports say “the device worked as designed” and hence conclude that operator behaviour, training or mismanagement is the key causal factor.

This talk will show how very poor the “state of the art” in interactive medical device design is, and it will raise some concrete ideas for remedies. The talk will be illustrated by examples of designed-in (but avoidable) latent errors in drug delivery systems.