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The visible and the stronginvisiblestrong Distributed Cognition for.pdf

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The visible and the invisible: Distributed Cognition for medical devices Dominic Furniss, Ann Blandford, Atish Astrid Mayer Rajkomar Chris Vincent Department of Oncology UCLIC Royal Free NHS Trust UCL, Gower Street Pond Street London WC1E 6BT, UK London, NW3 2QG, UK +44 20 7679 0688 a.blandford@ucl.ac.uk provoke further discussion – e.g. the cases of Denise ABSTRACT Melanson [10] and Lisa Norris [16]. However, such high Many interactive medical devices are less easy to use than profile incidents are mercifully rare, and many incidents are they might be, and do not fit as well as they could in their minor and may not be reported at all. For example, Husch contexts of use. Occasionally, the deficiencies lead to et al. [7] suggest that few incidents are reported. In a study serious incidents; more often, they have a less visible effect of infusion pump use in a busy hospital, covering 426 on the resilience and efficiency of healthcare systems. intravenous infusions, they identified a total of 389 errors, These issues remain largely invisible as they are not occurring in 285 of the infusions. In other words, 2/3 of the reported an