Unremarkable errors: low-level disturbances in infusion pump use

In this paper we describe results from an exploratory study observing infusion pump use in practice. From 31 observations of pump programming we note 10 low-level disturbances, which we conceptualise in terms of unremarkable error. This data supports a view that well performing systems cope with error as part of their normal work. Users are able to recover from error and are resilient to performance deviations. However, it is not clear how we, as HCI researchers, should respond to these minor errors: should we aim to minimise them or instead aim to improve detection, recovery and control in safety-critical systems? What is clear is that without remarking on unremarkable error we cannot begin this dialogue and consider the handling of these issues. To conclude we recognise four important factors that influence remedial action, and we highlight the need for a socio-technical approach for making change that is appropriate for practice

7 Themes for guiding situated ergonomic assessments of medical devices: a case study of an inpatient glucometer

There is relatively little guidance on the situated ergonomic assessment of medical devices, and few case studies that detail this type of evaluation. This paper reports results of a detailed case study that focuses on the design and use of a modern blood glucose meter on an oncology ward. We spent approximately 150 h in-situ, over 11 days and 4 nights, performing observations and interviews with users. This was complemented by interviews with two staff with oversight and management responsibility related to the device. We identified 19 issues with the design and use of this device. These issues were grouped into 7 themes which can help guide the situated study of medical devices: usability, knowledge gaps and mental models, workarounds, wider tasks and equipment, the patient, connection between services, and policy