The Science Journal of the American Association for Respiratory Care

2006 OPEN FORUM Abstracts

Evaluation of the User-Interface Simplicity and Human Errors in the Modern Generation of Mechanical Ventilators

Yoshihiro Uzawa,RRT,CPFT,RPT,1) Yoshitsugu Yamada MD,PhD2) Masayuki Suzukawa, MD,PhD3)  1) Kameda Medical Center, Chiba, Japan, 2) Tokyo University, School of Medicine, Tokyo, Japan, 3) Jichi Medical School, Tochigi, Japan

Background: Modern generation ventilators have evolved from a simple pneumatic system to highly sophisticated, microprocessor-operated devices. While this evolution has greatly improved the ventilator performance, human errors and human error-related ventilator incidents happen from time to time. How well the man-machine interface is designed could be an important factor to reduce the human error-related ventilator incidents. Study objectives: We designed this study to evaluate the simplicity of the user interface and human errors in modern generation mechanical ventilators. Subjects: Twenty-one medical resident physicians and eleven experienced physicians.

Four modern mechanical ventilators were selected. Each subject was requested to operate a total of eight tasks that were frequently conducted daily at bedside, on the following ventilators, Drager Evita XL, Maquet Servo-i, Newport e500, and Tyco PB840. Two objective parameters (the number of successfully completed tasks without mistakes and the time until the completion of tasks) and the overall subjective rating of the ease of use measured by a 100mm Visual Analog Scale were recorded.

Results: For all tasks, residents group made 23% of errors, while experienced group made 11%. There were significant differences in the rates of human errors among the four selected ventilators in both groups. Operators made more human errors in setting-up ventilators and in making setting changes than in reacting to alarms. The subjective feelings of the ease of use were also significantly different toward different ventilators.

Conclusion: The design of the man-machine interface is relevant to the occurrence of human errors, although the experience reduces the chance of them. Our data also indicate that ventilator designers could optimize the man-machine interface design to reduce the human errors; and medical training shall be tailored to the operation knowledge of specific ventilators used.
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