HUMAN-COMPUTER INTERACTION IN CONTEXT: PHYSICIAN INTERACTION WITH AUTOMATED INTRAVENOUS CONTROLLERS IN THE HEART ROOM

Abstract One result of recent research on human error and disaster is that the design of the human-machine system, defined broadly, modulates the potential for erroneous action. Clumsy space use of technological powers can create additional mental burdens or other constraints on human performance that can increase the chances of erroneous actions by people especially in high workload, high tempo operations. This paper describes studies of a computer based automated device that combine critical incident analysis, bench test evaluations of the device, and field observation in order to understand physician-device interaction in the context of heart surgery. The results link, for the same device, user group and context, three findings. First, the device exhibits classic human-computer interaction flaws such as lack of feedback on device state and behavior. Second, these HCI flaws actually do increase the potential for erroneous actions and increase the potential for erroneous assessments of device state and behavior. The potential for erroneous state assessment is especially troublesome because it impairs the user’s ability to detect and recover from misassemblies, misoperations and device failures. Third, these data plus critical incident studies directly implicate the increased potential for erroneous setup and the decreased ability to detect errors as one kind of important contributor to actual incidents. The increased potential for error that emanates from poor human-computer interaction is one type of latent failure that can be activated and progress towards disaster given the presence of other potentiating factors in Reason’s model of the anatomy of disasters.