Using Nomograms to Reduce Harm from Clinical Calculations

Handheld calculators and computer spreadsheets are ubiquitous and taken for granted. However in hospitals, errors in routine calculations frequently occur - for instance after making an unnoticed typing slip, such as omitting a decimal point in a drug dose calculation - and can result in patient harm. This paper is concerned with dependable calculation, and examines user tasks and technologies for safer calculations in the clinical environment. We demonstrate significant differences in complexity, speed and accuracy between alternative methods of performing calculations. The recent raised awareness of latent coding errors in applications designed to perfom medical dosage calculations has resulted in the introduction of national regulations that require all medical apps to meet similar standards of safety and reliability as other items of medical equipment. This paper provides evidence that general purpose calculators are also unnecessarily hazardous in the clinical environment, and should be subject to similar regulation. This paper contributes to the current debate about the use of computer systems to improve healthcare, and argues that "the latest IT" does not automatically confer benefit: its effectiveness should be empirically evaluated like any other medical intervention. The combination of simple reliable low technology graphical calculation aids and high technology computers with touch screen interfaces offers potential for improvement in patient safety, however further development and stringent evaluation are required before deployment in safety critical environments.

[1]  Walter M. Boothby,et al.  Nomographic Charts for the Calculation of the Metabolic Rate by the Gasometer Method , 1921 .

[2]  K ENGEL,et al.  A new acid-base nomogram. An improved method for the calculation of the relevant blood acid-base data. , 1960, Scandinavian journal of clinical and laboratory investigation.

[3]  Richard M. Young,et al.  The Machine Inside the Machine: Users' Models of Pocket Calculators , 1981, Int. J. Man Mach. Stud..

[4]  Richard E. Mayer,et al.  Psychology of calculator languages: a framework for describing differences in users' knowledge , 1981, CACM.

[5]  Thomas P. Moran,et al.  Mental models and problem solving in using a calculator , 1983, CHI '83.

[6]  N. Laird,et al.  Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention , 1995 .

[7]  Thomas K. Landauer,et al.  The trouble with computers , 1995 .

[8]  D S Stein,et al.  Factors related to errors in medication prescribing. , 1997, JAMA.

[9]  Harold W. Thimbleby,et al.  Calculators are needlessly bad , 2000, Int. J. Hum. Comput. Stud..

[10]  C. Vincent,et al.  Adverse events in British hospitals: preliminary retrospective record review , 2001, BMJ : British Medical Journal.

[11]  Chris Sangwin Newton's polynomial solver , 2003 .

[12]  William Thimbleby A novel pen-based calculator and its evaluation , 2004, NordiCHI '04.

[13]  S. Hettiaratchy,et al.  Initial management of a major burn: II—assessment and resuscitation , 2004, BMJ : British Medical Journal.

[14]  Y. Han,et al.  Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2005, Pediatrics.

[15]  Morton F Arnsdorf,et al.  The prognostic value of a nomogram for exercise capacity in women. , 2005, The New England journal of medicine.

[16]  Mary L. Cummings,et al.  Utilizing Ecological Perception to Support Precision Lunar Landing , 2006 .

[17]  M. Alexander To Err is Human. , 2006, Journal of infusion nursing : the official publication of the Infusion Nurses Society.

[18]  N. D. Nguyen,et al.  Development of a nomogram for individualizing hip fracture risk in men and women , 2007, Osteoporosis International.

[19]  Harold W. Thimbleby,et al.  FEATUREIgnorance of interaction programming is killing people , 2008, INTR.

[20]  Mitsuhiko Noda,et al.  BMI nomogram [corrected]. , 2008, Clinical nutrition.

[21]  David A Grimes,et al.  The Nomogram Epidemic: Resurgence of a Medical Relic , 2008, Annals of Internal Medicine.

[22]  Samuel Zwillich,et al.  Where Is the Evidence That the Resurgence of Nomograms Is Harmful? , 2009, Annals of Internal Medicine.

[23]  David A. Grimes,et al.  Where Is the Evidence That the Resurgence of Nomograms Is Harmful , 2009 .

[24]  A. Gawande,et al.  The Checklist Manifesto , 2009 .

[25]  Harold W. Thimbleby,et al.  Contributing to safety and due diligence in safety-critical interactive systems development by generating and analyzing finite state models , 2009, EICS '09.

[26]  R. Ferner,et al.  The pathophysiology of medication errors: how and where they arise. , 2009, British journal of clinical pharmacology.

[27]  Harold Thimbleby,et al.  Reducing number entry errors: solving a widespread, serious problem , 2010, Journal of The Royal Society Interface.

[28]  M. Kattan,et al.  What is a real nomogram? , 2010, Seminars in oncology.

[29]  George Downie,et al.  Comprar Calculating Drug Doses Safely, 2nd Edition | George Downie | 9780702031847 | Churchill Livingstone , 2010 .

[30]  David Williams Nomograms to aid fluid resuscitation in acute burns. , 2011, Burns : journal of the International Society for Burn Injuries.

[31]  Harold W. Thimbleby,et al.  Number Entry Interfaces and Their Effects on Error Detection , 2011, INTERACT.

[32]  Amy J Barton,et al.  The regulation of mobile health applications , 2012, BMC Medicine.

[33]  David Williams,et al.  Graphic Aids for Calculation of Fluid Resuscitation Requirements in Pediatric Burns , 2012, Annals of plastic surgery.

[34]  Alexander Zlotnik,et al.  The neuroprotective effects of oxaloacetate and puruvate in a rat model of subarachnoid hemorrhage is mediated by its blood glutamate scavenging activity: ESAPC1-1 , 2013 .

[35]  Owen Bodger,et al.  Comparison of three techniques using the Parkland Formula to aid fluid resuscitation in adult burns , 2013, Emergency Medicine Journal.

[36]  Ross Koppel,et al.  First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety , 2013 .

[37]  J. D. Walker,et al.  A nomogram to calculate estimated glomerular filtration rate (eGFR): 9AP5-4 , 2013 .

[38]  Harold W. Thimbleby,et al.  Reasons to question seven segment displays , 2013, CHI.

[39]  J. D. Walker,et al.  A nomogram to prevent local anaesthetic toxicity: 17AP4-1 , 2013 .

[40]  J. D. Walker,et al.  A nomogram to calculate physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM): 17AP1-6 , 2013 .

[41]  Owen Bodger,et al.  Comparison of three techniques for calculation of the Parkland formula to aid fluid resuscitation in paediatric burns , 2013, European journal of anaesthesiology.

[42]  J. D. Walker,et al.  A nomogram to calculate the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) , 2014, The British journal of surgery.

[43]  Michael R. Cohen Medication errors. , 2014, Nursing.

[44]  David Robson,et al.  A dangerous prescription , 2014 .