Human Error in Patient-Controlled Analgesia: Incident Reports and Experimental Evaluation

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Abstract
Human error is often cited as the most common cause of medical device mishaps. The role that a poorly designed user interface plays in precipitating these errors is infrequently acknowledged. This study focused on the Abbott PCA Infuser, a commonly used medical device. A review of FDA incident reports showed that human error is responsible for 68% of fatalities and serious injuries associated with the Abbott PCA. We sought to demonstrate that the incidence of human error can be significantly reduced through a human factors approach to interface design. A redesigned interface was developed, then empirically evaluated with a group of recovery room nurses, experienced PCA users. The results of the evaluations showed a 55% reduction in errors, an 18% improvement in performance time, a 14% reduction in mental workload, and a strong preference by nurses for the redesigned interface. These findings demonstrate that quantifiable improvements in equipment safety and efficiency can be achieved by adopting a human factors approach to interface design.

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