The Practice of Emergency Medicine/ConceptsHuman factors and ergonomics in the emergency department*
Introduction
Ergonomics (or human factors engineering) is formally defined as the study of how human beings interact with their environment for useful purposes. A more focused but less formal definition is that it is the study of factors that make work easy or hard. Although ergonomic analyses have been widely used in industry, they have been conspicuously absent in health care. Indeed, a health care organization that used human factors engineering to improve its workplaces would be a rarity. This is in sharp contrast with other complex, high-risk enterprises, such as aviation, electrical power generation, or petroleum refining. A variety of cultural and organizational factors have led to this state of affairs,1 but 4 are worth emphasizing.
The first is the great value that we as health professionals place on personal responsibility for outcomes. This value is deeply internalized by health professionals and frequently reinforced in our collegial interactions. We have been trained to feel that, if we were just alert enough, smart enough, and dedicated enough, we should have been able to overcome whatever ergonomic impediments we encountered. Because of this, we tend to accept personal explanations of failure as sufficient and do not look beyond them for factors that are perhaps more amenable to improvement.
The second is the lack of well-defined resources in health care organizations where human factors issues might be addressed. When we do become aware of ergonomic difficulties, we may pause to curse them briefly, but we have no means with which to attack them.
The third is the decentralization of authority and fragmentation of work in health care organizations without compensating centralization on key values.2 Efforts to improve the system tend to be narrowly focused, leading to optimizations in one area with effects that are at best unknown and at worst harmful when care crosses into another.
And the fourth is the persistence of the “guild and workshop” model, in which guilds of physicians function almost independently of the health care organization and have little investment in organizational safety beyond their own individual actions.
The result is that, with the notable exception of anesthesiologists,3, 4, 5 clinicians discount ergonomics and human factors to such an extent that most are as unaware of them as fish are unaware of water. Not surprisingly, experts on human performance and human error have called the medical workplace “an ergonomic nightmare.”6 We report a case that we believe is not at all atypical and analyze it from an ergonomic point of view to illustrate the influence of factors, heretofore inapparent, obscure, or presumed to be intractable. Our goal is to raise awareness, to “remove the blinders,” and to establish ergonomic problems as a legitimate topic for discussion, research, and improvement in health care.
Section snippets
The case
A 52-year-old man presented to the emergency department at approximately 9 PM , complaining of headache and general malaise. He had a history of uncontrolled hypertension and insulin-dependent diabetes mellitus. Approximately 30 minutes before admission, he complained of severe headache and generally feeling bad, and asked to be taken to the hospital. At triage, he was noted to be diaphoretic and not moving his left side. He was alert, responsive, and able to speak, with a Glasgow Coma Scale
Discussion
Although this is only a single case from a single ED, we believe the general principles will resonate with clinicians. Every emergency physician or nurse has experienced the equivalent of this case; most of us have had more than we care to remember. The staff in this case did not express frustration or anxiety as a result of the many impediments they encountered; to them, this was “just business as usual.” What is remarkable about this case is not the number of things that went wrong, but the
Acknowledgements
We thank an anonymous reviewer for helpful comments on the Discussion.
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Address for correspondence: Robert L. Wears, MD, MS, 655 West 8th Street, Jacksonville, FL 32209; 904-244-4124, fax 904-244-4508; E-mail [email protected]. Reprints not available from the authors.