Systems mapping workshops have been applied to the problem of medication errors in healthcare. The workshops were designed using experiential group work principles. They involved a range of stakeholders from within the health service as well as those who supply the health sector, including designers who may be able to enhance the safety of products and systems used in healthcare. Research has shown that the method encourages stakeholder participation, provides robust results within a limited time and enhances understanding across specialist interest groups. Additional, creative design workshops that considered the same topic showed significant promise in developing concepts from which potential solutions could be developed further.@en

In the light of a number of serious incidents in the UK resulting from accidental overdoses of methotrexate, this study investigated how the design of methotrexate packaging can influence patient safety, and aimed to collect evidence to provide a basis for the development of new concepts for revised designs by the pharmaceutical industry. The research found that patients using methotrexate experience a number of difficulties in using their medicines packaging, and as a result, resourcefully adopt a variety of " coping strategies" which may increase the risk of dosing errors. By investigating both the practice of methotrexate users, and the design of the system that supports methotrexate use, additional problems were observed across the healthcare system, meaning that the function of medicines packaging in ensuring safety may be even more critical than first suspected. As a result of this research the National Patient Safety Agency responded with a UK-wide programme of work to improve safety for patients, and continues to work with the pharmaceutical industry to develop more user-friendly packaging and labelling.

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The complexity of the health care environments necessitates an holistic and systematic ergonomics approach to understand the potential for accidents and errors to occur. The health service is also a socio-technical system, and design needs must be met within this context. This paper aims to present the design challenges and emphasises the specialised needs of the health care sector, when dealing with patient safety. It also provides examples of approaches and methods that ergonomists can bring to help inform our knowledge of these systems and the potential towards improving their safety. Mapping workshops provide an example of such methods. Results from these are used to illustrate how the knowledge base required for better design requirements can be generated. The workshops were developed specifically to help improve the design of medication packaging and thereby reduce the probability of medication error. The issues raised are now the subject of further research, design requirements guidance and new design concepts. The paper illustrates the need to engage with the design community and, through the use of robust scientific methods, to generate appropriate design requirements.@en

Despite advances in engineering knowledge and technology the everyday experience of the engineered world provides, all too often, evidence of failure as well as success. For example, as a literate and healthy human is it unreasonable to expect: • to be readily able to set the alarm function on my digital watch and to be confident that it will work? • to be able to read the instructions on food packaging? • to correctly change batteries, first time, on an electric toothbrush? • not to have to move every few minutes to prevent the office being plunged into darkness by a motion sensitive, power-saving system? • to have my 'patient's notes' present at the same time as myself in an otherwise high-tech clinic? All these problems, and more, have beset our group recently.The list is long, the explanation occasionally obvious (for example, the batteries were inserted incorrectly because it is almost impossible to see the polarity signs embossed on the internal base of the toothbrush battery casing) but the implications for engineering are enormous. Quite simply, they force us to ask whether the engineering process itself is correct. All engineered environments and artefacts have human involvement. Even so-called 'fully automated processes' are anything but that. On analysis we find that they are specified and designed by humans, tested by humans, commissioned by humans, maintained by humans, and subsequently decommissioned and disposed of by humans.The need for a systematic approach to design that is inclusive of 'the human factor' is evident, but is it acted upon? Even when the 'human factor' in the system is considered, it is often forgotten that whilst humans may come as individuals, they always work as groups, teams, organisations and, even, societies. Understanding the resultant needs, behaviours and attitudes is integral to systems engineering. Pheasant (1996) identified five fallacies of engineering design (Table 3.1).The common thread that runs through them all is the need to recognise that design, to be successful, must adopt a systems approach. How then to avoid such traps and develop systems that truly reflect modern thinking and knowledge? The following sections present an introduction to systems engineering and ergonomics, focusing on the way in which they should influence the design process. Examples are presented to illustrate the key issues. Many are from the healthcare industry, where safety can only assured if a systems approach is adopted.

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The Design for Patient Safety Study showed that the National Health Service (NHS) is seriously out of step with modern thinking and practice with regard to design. The study emphasises the need to move to a user-centred systems approach to designing in healthcare, without which patient safety will remain a significant challenge for the foreseeable future. The development of the MRC/EPSRC/ESRC Design for Patient Safety Network is addressing some of the research issues raised by the need for a systems approach.@en

Solid oral Methotrexate (Methotrexate in tablet form) has been used for many years as an effective measure to treat severe rheumatoid arthritis and severe psoriasis. When taken at the right frequency and dose Methotrexate is a safe medication. However, in the community in the UK between 1993 and 2000, Methotrexate has been implicated in the deaths of some 25 patients and a further 26 cases of serious harm which have required hospitalisation [1,2]. In 2003 the National Patient Safety Agency (NPSA) began a programme of work to investigate the causes of errors with Methotrexate and to develop and implement solutions in response. Since then, three projects have been undertaken: The development of a new patient treatment diary; An investigation of IT systems in GP's surgeries and community pharmacies; and An assessment of the packaging and labelling of Methotrexate with patients and healthcare practitioners and the identification of changes which should improve patient safety. This paper describes the research and results from the third project.

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The Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the NHS. The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the health care system as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.@en

In 2002 the UK Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the National Health Service (NHS). The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries in order to ascertain how the design of systems - equipment and other physical artefacts, working practices and information - could contribute to patient safety. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the healthcare system, including the users of that system, as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.

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