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Investigating the unremarkable, routine and normal

Key points

  • Unremarkable simply means that something is not remarked upon. This could be because it is not noticed, it is uninteresting, it is assumed to be normal or the person does not want to draw attention to it. We have found this area to be both important and enlightening for healthcare.
  • We have examined unremarkable errors in normal work, made disruptive device interactions visible, and highlighted routine issues in clinicians’ work and from the patient’s perspective.
  • We have applied theory from ‘unremarkable computing’ to healthcare. We propose a research agenda that focuses on the unremarkable and routine that aims to make computing invisible-in-use.

Background
When significant error and harm is caused in healthcare there are systems in place to investigate what happened and learn from what went wrong. These events are considered abnormal and so we treat them differently, with more attention. However, normal practice has a big role to play in our wider understanding of safety, issues in the everyday use of medical devices, routine clinical work, patient care and organisational learning. The normal and the mundane should not be overlooked.

Unremarkable errors and routines in practice
Through careful observations of nurses programming infusion pumps in an oncology day care unit, we noted many unremarkable errors and discrepancies that were caught and recovered from before they could develop. We also documented the unwritten rules and informal resilience strategies that nurses use to reduce the likelihood of error. For example, nurses used cardboard trays to organise their treatments so that they could better monitor  what they were doing and detect errors. The way nurses organise their work impacts the likelihood of error.

Everyday disruptive devices
We also documented the use of disruptive devices that clinicians and patients have to live with everyday in hospitals. For example, an oximeter’s alarm disturbed a patient and his family whilst his condition deteriorated because the nurse could not control it. Nurses and patients on a haematology ward found the infusion pump alarms a nuisance, which led to workarounds, policy violations and errors in practice. We also studied the use of a modern blood glucose meter in detail, and revealed many issues and workarounds to do with its design and use. As a result we have suggested design recommendations.

Organisational learning and reporting systems
Learning and reporting systems, both at a hospital and a national level, often focus on the most significant errors and harmful incidents. In contrast, we highlight the potential for alternative learning and reporting systems that pay attention to ordinary, everyday clinical work that can derive useful learning and active discussion about clinical risk. Our studies have highlighted that innovations in learning and reporting systems come from both traditional organisational channels, and through social media and groups external to the normal organisational structure.

An agenda for considering unremarkable computing for healthcare
Unremarkable computing focuses on digital interventions that seamlessly fit routine practices, so they are ‘invisible-in-use’. We have explored how some of the principles of unremarkable computing apply to healthcare. This has not been done before. We have identified a research agenda to explore this further, to understand unremarkable routines, to reduce disruptive design, and look at both the unremarkable and the remarkable perspectives of different groups in healthcare (most notably clinicians and patients).

References
Furniss, D., Blandford, A. & Mayer, A. (2011). Considering Unremarkable Computing for Healthcare. Workshop on Interactive Systems in Healthcare. WISH 2011 with AMIA, October 22, 2011, Washington, DC.

Furniss, D., Back, J. & Blandford, A. (2011). Unwritten Rules for Safety and Performance in an Oncology Day Care Unit: Testing the Resilience Markers Framework. Proc. Fourth Resilience Engineering Symposium.

Furniss, D., Blandford, A. & Mayer, A. (2011). Unremarkable errors: Low-level disturbances in infusion pump use. Proc. British HCI.

Furniss, D., Blandford, A., Mayer, A., Rajkomar, A. & Vincent, C. (2011). The visible and the invisible: Distributed Cognition for medical devices. Proc. EICS4Med.

Furniss, D. (2013). HCI Observations on an Oncology Ward: A Fieldworker’s Experience. In CHI 2013 workshop: HCI Fieldwork in Healthcare – Creating a Graduate Guidebook.

Blandford, A., Back, J., Cox, A., Furniss, D., Iacovides, I. & Vincent, C. (2014). Closing the virtuous circle: Making the nuances of infusion pump use visible. HFES 2014 International Symposium on Human Factors and Ergonomics in Health Care: Leading the Way.

Furniss, D., Blandford, A. & Mayer, A.(2014). The Wrong Trousers: Misattributing medical device issues to the wrong part of the sociotechnical system. In CHI 2014 workshop: HCI Research in Healthcare: Using Theory from Evidence to Practice.

Furniss, D., Masci, P., Curzon, P., Mayer, A. & Blandford, A. (2014) 7 Themes for guiding situated ergonomic assessments of medical devices: A case study of an inpatient glucometer. Applied Ergonomics. Available online 20 June 2014.

Blandford, A., Furniss, D. & Vincent, C. (2014). Patient Safety and Interactive Medical Devices: Realigning work as imagined and work as done. Clinical Risk.

Sujan, M. & Furniss, D. (2015). Organisational Reporting and Learning Systems: Innovating Inside and Outside of the Box. Journal of Clinical Risk.

Furniss, D., Masci, P., Curzon, P., Mayer, A. & Blandford, A. (2015). Exploring Medical Device Design and Use Through Layers of Distributed Cognition: How a glucometer is coupled with its context. Journal of Biomedical Informatics.

Key people
Dominic Furniss, Astrid Mayer, Ann Blandford