September 7, 2011

2 Min Read
Open Discussion: How Would You Solve This Human Factors Problem?

The Set Up: A clinic nurse in Madison, WI, is reported to have misused equipment for teaching patients to inject insulin. The nurse changed the needle in the insulin pen and the lancet used to extract a drop of blood—but she reused the insulin pens and finger-stick devices, according to reports.

The Human Factor: The nurse is a certified diabetes educator, trained to show diabetic patients how to inject insulin and test blood sugar levels. For training purposes, the insulin pens were to be used only on objects, such as oranges, for demonstration—not on patients.

The Result: Diabetic patients who may have been exposed to blood-borne diseases at the clinic are now being tested for hepatitis and HIV.

The Risks: Although such a mistake is rare in a clinical setting, federal officials are concerned about the risks of transmitting blood-borne viruses when diabetics are assisted with testing their blood sugar levels and insulin injections, and equipment is unsafely reused on multiple patients. At a health fair in New Mexico in 2010, dozens of attendees were potentially exposed to blood-borne viruses when finger-stick devices were inappropriately reused for multiple people to conduct diabetes screening. At a hospital in Texas in 2009, more than 2000 people were advised to undergo testing for blood-borne viruses after individual insulin pens were used for multiple patients. Schools and camps may be equally at risk.

The Analysis: "The question is whether the blood glucose monitoring system could be designed to prevent the type of error that caused the infections," says Steve Wilcox. He says the role of human factors in infection control is very interesting. "There are systems that basically force the physicians to wash their hands in a clinical setting. Infection control can be improved by a system that constrains the conduct of the medical professionals."


When we work on device development projects, one of the original design requirements has to be failure of causing inadvertent infection. Then it's the development team's job to reduce the potential as much as possible. A problem can arise if the issue isn't on the team's radar screen in the beginning, or if it is, but they don't come up with a good solution."

The Challenge: How would you approach this human factors conundrum? Is there a way to design insulin pens and finger sticks so that untrained or maybe absent-minded clinicians. I'm not asking you to reveal secrets, but what are some of the approaches you would take in design? 

—Heather Thompson

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