Iacovides Ioanna, Blandford Ann, Cox Anna, Back Jonathan
1Institute of Educational Technology, The Open University, Walton Hall, Milton Keynes, MK76AA UK.
2UCL Interaction Centre, University College London, 62-77 Gower Street, London, WC1E 6BT UK.
Cogn Technol Work. 2016;18(4):793-805. doi: 10.1007/s10111-016-0392-0. Epub 2016 Sep 21.
Human error can have potentially devastating consequences in contexts such as healthcare, but there is a rarely a simple dichotomy between errors and correct behaviour. Furthermore, there has been little consideration of how the activities of users (erroneous and otherwise) relate to the conceptual fit between user and device, despite the fact that healthcare technologies are becoming increasingly prevalent and complex. In this article, we present a study in which nurses' conceptions of infusion device practice were elicited to identify misfits. By focusing on key concepts that users work with when setting up infusions and the extent to which the system supports them, our analysis highlights how actions are influenced by the different resources available to users including: the device itself; supporting artefacts; the conceptual understanding of the user; and the community of practice the user is part of. The findings reveal the ways in which users are resourceful in their day-to-day activities and also suggest potential vulnerabilities within the wider system that could threaten patient safety. Our approach is able to make previously under-explored aspects of practice visible, thus enabling insight into how users act and why.
在医疗保健等领域，人为错误可能会带来潜在的灾难性后果，但错误与正确行为之间很少存在简单的二分法。此外，尽管医疗技术越来越普及和复杂，但很少有人考虑用户的活动（无论是否错误）与用户和设备之间的概念契合度是如何关联的。在本文中，我们展示了一项研究，该研究引出了护士对输液设备操作的概念，以识别不匹配之处。通过关注用户在设置输液时所使用的关键概念以及系统对他们的支持程度，我们的分析突出了行动是如何受到用户可利用的不同资源影响的，这些资源包括：设备本身；辅助工具；用户的概念理解；以及用户所属的实践社区。研究结果揭示了用户在日常活动中足智多谋的方式，也表明了更广泛系统中可能威胁患者安全的潜在漏洞。我们的方法能够使之前未被充分探索的实践方面显现出来，从而有助于深入了解用户的行为方式及其原因。
