Magazine article American Nurse Today

Nursing Practice and Work Environment: Designing Equipment and Devices for Safety: A Role for Nursing Advocacy

Magazine article American Nurse Today

Nursing Practice and Work Environment: Designing Equipment and Devices for Safety: A Role for Nursing Advocacy

Article excerpt

A PATIENT was admitted to the hospital for uncontrolled diabetes. A nurse taking care of her checked her blood glucose level. The glucometer showed the patient's blood level was dangerously high. Repeated tests yielded the same result.

The patient was given insulin and her condition deteriorated. The rapid response team was called. The patient was in a diabetic coma. She was given multiple doses of glucose and transferred to the intensive care unit. The human resources department suspended the nurse.

Another nurse in the same healthcare system had made the same apparent mistake a few days earlier. This sequence of events prompted safety leadership to request a human-factors review of the glucometer. When the engineers simulated the use of the glucometer, a pop-up text box appeared, which read, "Critical Value, Repeat Lab draw for > 600." This is the message the nurse saw. It obscured the actual blood glucose reading, which was low.

Hospital staff had customized the glucometer so a pop-up message would alert users to critical readings. But the pop-up message partially covered the actual glucose reading. Why would a glucometer be designed to allow the blood glucose reading to be partially hidden?

The patient recovered. She was informed of the events and received an apology. The nurse was reinstated and the hospital apologized to her. The nurse agreed to be interviewed; her interview can be found at https://wwwyoutube.com/watch?v=yVSd7zqmjM.

Human factors is a scientific discipline that studies how human beings interact with technology and equipment. A guiding principle is that equipment and devices should be designed to match the cognitive process and environments of users. Human-factors engineering principles are applied in airplane cockpits; no new equipment or software is used without thorough testing for safety, reliability, and interoperability with other equipment. …

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