DOME - Designing Out Medical Error: Establishing Performance Requirements for Equipment Use on Hospital Wards

Lead Research Organisation: Royal College of Art
Department Name: Helen Hamlyn Centre for Design

Abstract

The challengeHuman error and systemic failure lead to unnecessary harm and suffering for patients, including permanent impairment and loss of life. Research indicates that in up to 10% of all hospitals admissions some kind of adverse incident occurs, more than half of which are believed to be avoidable. The effect on staff and the 2billion+ consequential costs further increase the need to improve all aspects of patient safety. A significant contributory factor is that healthcare processes have undergone many revisions in recent years, while the design of much non-surgical equipment remains largely unchanged. Modern healthcare involves a combination of processes and procedures supported by a broad range of equipment and products that have to co-exist within the 'patient cubicle' or ward treatment space. Few of these have been designed to ensure safe integration within the context of use, be it ward, theatre, or community, nor is this a purchasing requirement within NHS Trusts. In short, current treatments are not properly and effectively supported by available equipment. Research aimsThe outcomes of this research will be both patient and system aware. The aims are to enhance patient safety in hospital by designing out medical error, to ensure that medical products and equipment are fit for purpose, and to contain risks associated with the introduction of new designs into a system of great complexity. The Chief Medical Officer recognises the potential of a design-led approach to patient safety and wishes to see it adopted more widely across the NHS. To design out medical error it is necessary to: (i) understand healthcare process demands with regard to diagnostic, monitoring and treatment routines, in particular in terms of the consistency and usability of interfaces and other features, and in light of the progressive introduction of 'smart' products and equipment; (ii) translate that understanding into a knowledge base for the design of medical products and equipment that support safer and more effective healthcare processes; (iii) establish a best-practice, evidence-based approach to the design, equivalent to that underpinning the development of treatments, procedures and medication regimes in modern medicine. Research approachWe will use both global and candidate approaches in the project. The global approach will follow a systematic methodology to capture the broader system of healthcare process and ensure there are no gaps in our understanding of the patients/system interactions. In addition, we identified from our clinical observations and design perspective, three candidates that require detailed attention in the project: (i) the communication process in the ward; (ii) the patient local environment personal cubicle and (iii) the ward clinical activity.In order to address the broader challenge of equipment and products in use on the hospital ward, a Consultant Surgeon and Clinical Reader at Imperial, Mr George Hanna, who has research interest in ergonomics, instrument design and surgical safety will lead the clinical side of the programme. Professor Charles Vincent will lead on healthcare process and patient safety aspects, and PhDs will be attached to each of these strands to build up a cadre of young researchers in the field.DeliverablesThe project will have the following deliverables (i) a thorough map of healthcare processes both on a ward and within the broader context of the patient journey (ii) comprehensive knowledge of the design requirements for ward equipment; (iii) design proposals for a ward communication system, (iv) design proposals for a ward treatment space or 'patient cubicle' and (v) guidelines for safe ward activities and staffing levels.

Publications

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Anderson O (2013) Surgical adverse events: a systematic review. in American journal of surgery

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Anderson O (2011) Interventions designed to prevent healthcare bed-related injuries in patients. in The Cochrane database of systematic reviews

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Anderson Oliver (2011) Make it Better

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Anderson, O. (2010) Evaluating innovation in Showcase Hospitals: Innovation and technology for combating healthcare associated infection

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Anderson, O. (2010) Design for patient safety in International Society of Quality and Safety in Healthcare (ISQua)

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Fakhry M (2012) Effectiveness of an audible reminder on hand hygiene adherence. in American journal of infection control

 
Description One in ten hospital patients in the UK suffers unintended harm as a result of medical error. The Design for Patient Safety report (2003) revealed that the design of hospital equipment, medical devices and environments can increase the potential for error.

Modern healthcare involves a complex interaction between people, equipment, space and clinical procedures - but much current design is developed without sufficient understanding of how interfaces and devices fit within a bigger context of use and mistakes occur as a result.

The DOME (Designing Out Medical Error) project took a multidisciplinary approach, bringing a team of clinicians, designers, psychologists, ergonomists and business experts together (from RCA and Imperial College London) to view the problem of medical error in the round. The aim was to better understand and map healthcare processes on surgical wards and establish an evidence base to design better products and interfaces to reduce instances of medical error.

The team began by observing and mapping the patient journey through elective surgery, from admission to discharge. Every step was documented, as well as equipment used, environments visited and personnel involved. This mapping exercise served as context for more focused research on the ward. An audit of common healthcare processes at the bedside was carried out, and a hazard scoring system was adapted from industry to assess and rank the relative risk of each process.

Study of analogous industries that have developed design strategies to manage risk (such as mining, construction and chemical plants) also led to a number of insights that influenced the design approach to the hospital bed space. The five most risky processes were identified and investigated further, with more in-depth analysis of errors and their causes. This led to a sound evidence base for five design briefs, each centred on a healthcare process: hand hygiene, handover, vital signs measurement, medication, and infection control.

Creative techniques were used with clinicians to ensure a fully collaborative design process. Sketches and models were used for clinical feedback, and the concepts were refined into a suite of five designs, one per brief. The primary outcome of the project was the validation of the collaborative methodology outlined above. Emerging from this, the five design outputs have direct impact on the clinical space.

A new hand hygiene sign simplifies the visual message to staff to improve compliance with correct protocols. Furniture and lighting recommendations for a staff room create a better working space for a more effective handover. A new vital signs trolley improves the management of patient data as well as being easier to clean. New medication packaging provides the patient with simpler information about their drugs.

A new piece of ward furniture, the CareCentre, placed at the end of every bed, contains all the commonly used equipment for regular bedside care. This last design was trialled in a simulated ward environment, where nurses' interactions with the product were recorded and analysed. A more extended clinical trial of the design was conducted on a series of hospital wards. The results of both studies demonstrated that the design improves both the quality and efficiency of care.

Overall the DOME project developed a new design-led approach to cross-disciplinary collaboration aimed at educing medical error, and piloted this approach through the design and development of new products and services to improve safety in the hospital bed space. In layman's terms, this new approach can be described as akin to a rowing team in which everyone shares the effort and focus throughout the race, as opposed to a relay team in which the baton is passed successively from one discipline to the next.
Exploitation Route The results of the DOME project supported the thesis of the research - that patient safety can be improved through design, provided it is grounded in thorough research, and developed within a genuine multidisciplinary collaboration.

DOME is cited as a pathfinder for genuine interdisciplinary collaboration between the worlds of medicine, design and management with real-world practical examples of new product and service development resulting from the initiative. Its methodology has been disseminated for use by other healthcare development and hospital management teams.
Sectors Communities and Social Services/Policy,Healthcare,Manufacturing, including Industrial Biotechology,Retail

URL http://www1.imperial.ac.uk/cpssq/research_themes_2/cpssq_research_themes/dome/
 
Description The DOME research has a number of important beneficiaries in terms of impact, extending from the healthcare and design professions and industries to patients and their families who stand to benefit from improved healthcare processes leading to a reduced number of errors and an increase in the quality and safety of patient care. Findings in the UK, US, Australia, New Zealand and Denmark all suggest that some form of error occurs in about 10% of hospital admissions. In a significant number of cases the result is serious harm or death. Designing out medical errors before they occur is potentially one of the most effective ways to combat this problem. Adopting a system-aware, evidence-based, design-led strategy is key to the endeavour. This is what the DOME project identified, developed and piloted. The results of the DOME project supported the thesis of the research - that patient safety can be improved through design, provided it is grounded in thorough research, and developed within a genuine multidisciplinary collaboration. The development of the DOME design concepts received on-going input from frontline hospital staff and patients. As the designs became more resolved, more extensive testing was carried out in a simulated ward environment at St Mary's Hospital, London. Various clinical scenarios were played out by nurses using the new designs, which were improved as a result. The CareCentre and an iPhone App to measure respiratory rate (part of the Vital Signs trolley design) underwent formal trials, with the results published and used to improve the designs. Manufacturers Bristol Maid (UK) and Humanscale (USA) became involved in the development of the CareCentre and Vital Signs trolley respectively, and the designs were refined in partnership with them. A licence was given to Bristol Maid to manufacture the CareCentre and make it commercially available to the NHS. The research, methodology, designs and trial results were published within the team members' respective disciplines, and this work continues. An exhibition of the DOME innovations, entitled Make It Better, went on show at the Royal College of Art in London in September 2011 and then travelled to the Royal College of Surgeons Hunterian Museum in London (January 2012) and the Pontio centre for multidisciplinary design and innovation, Bangor University, North Wales (March 2012, supported by the European Commission). There was extensive media coverage including an editorial in The Lancet and a feature on the BBC News website. The project has been disseminated internationally, with the PI and research team making several keynote presentations, including at the King's Fund in London and at the International Society for Quality in Healthcare (ISQua) conference in Paris, the world's largest forum for this type of work. DOME has won prestigious awards for research in the UK and USA. There has also been extensive media coverage including an editorial in The Lancet and a feature on the BBC News website. DOME is cited as a pathfinder for genuine interdisciplinary collaboration between the worlds of medicine, design and management with real-world practical examples of new product and service development resulting from the initiative. The development of its methodology enabled the Helen Hamlyn Centre for Design to participate in three high-profile patient safety demonstration projects organised by the Department of Health and the Design Council . The first, Design Bugs Out (2009), responded to public outcry over dirty hospitals and resulted in a range of products which are easier to clean and less likely to trap bacteria. The second, Design for Patient Dignity (2010), responded to public outcry over the indignities of mixed sex wards and resulted in innovative products and systems to improve the patient experience. The third, Reducing Violence and Aggression in A&E (2011), adopted design principles to reduce incidents of violence while waiting in the emergency department through better information design and smarter processes. The DOME project served as a forerunner to the establishment of a new design-led innovation centre, the HELIX Centre, set up in November 2013 by original DOME partners RCA and Imperial with a £2.8 million grant for the HEFCE Catalyst Fund. This initiative embeds a team of designers inside a working London hospital, St Mary's at Paddington, and utilises many aspects of the DOME project in its approach - systems thinking, evidence-gathering, process mapping, user participation and rapid prototyping to achieve frugal, low-cost, high impact innovation in healthcare.
First Year Of Impact 2011
Sector Communities and Social Services/Policy,Construction,Creative Economy,Digital/Communication/Information Technologies (including Software),Education,Environment,Healthcare,Manufacturing, including Industrial Biotechology
Impact Types Societal,Economic

 
Description Bristol Maid 
Organisation Hospital Metalcraft Ltd
Country United Kingdom 
Sector Private 
PI Contribution RCA provided the design research, as well as initial concept development and validation
Collaborator Contribution Bristol Maid provided manufacturing knowledge, and produced 6 prototypes for clinical trials as part of a licence agreement.
Impact Carestations/CareCentres have been in use on hospital wards. As there is evidence showing improvements in staff workflow efficiency and adherence with infection control protocols (see IP and licensing outputs), it can be assumed that they had corresponding local benefit.
Start Year 2009
 
Title Carestation 
Description The design research on wards let to the creation of the Carestation (now CareCentre), a free-standing unit placed at the end of the hospital bed containing all equipment needed for common bedside tasks. 
IP Reference 001846650-0001, 001846650-0002 
Protection Patent granted
Year Protection Granted 2011
Licensed Yes
Impact The design completed clinical trials, demonstrating improved workflow efficiency and infection control protocol adherence.
 
Title CareCentre 
Description The CareCentre is a new piece of ward furniture, positioned at the end of the hospital bed. It contains aprons and gloves, alcohol gel, a flat surface for reading and writing documents, a medication drawer and cleaning wipes. It has been through three iterations, the design was licensed to Bristol Maid in 2011, and has since been commercially available. The research was funded by EPSRC, and some prototyping was done at Bristol Maid's expense. 
Type Support Tool - For Medical Intervention
Current Stage Of Development Wide-scale adoption
Year Development Stage Completed 2011
Development Status Under active development/distribution
Clinical Trial? Yes
Impact Direct impact (improvements in efficiency, and in adherence to infection control protocols) is proven through clinical trial, and it is therefore assumed to have impact on the wards where it is in use. More broadly, the design is often presented at conferences where the merits and impact of design are clearly illustrated for a clinical audience. 
 
Title Respiratory rate phone application 
Description The intervention is a simple app which improves the accuracy of manual respiratory rate recordings by allowing nurses to concentrate on the patient's breathing movements. It is now freely available to download. Research was funded by EPSRC. 
Type Products with applications outside of medicine
Current Stage Of Development Wide-scale adoption
Year Development Stage Completed 2012
Development Status Under active development/distribution
Clinical Trial? Yes
Impact As with the CareCentre, direct impact (improvements in measurement of respiratory rate) is proven through clinical trial, and it is therefore assumed to have impact on the wards where it is in use. More broadly, the design is often presented at conferences where the merits and impact of design are clearly illustrated for a clinical audience. 
URL https://itunes.apple.com/app/id573065068
 
Title Vital Signs Trolley 
Description The design is a new trolley to measure vital signs that is easier to clean and use - and captures and interprets data automatically. The screen guides the nurse through the correct procedure, captures all the data and automatically displays the figures on a chart. The screen also helps nurses to accurately measure respiratory rate. The cables retract back into the trolley, keeping it tidy and making it easier to clean. The research and initial prototyping was funded by the EPSRC. 
Type Support Tool - For Medical Intervention
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2011
Development Status On hold
Impact The design is often presented at conferences where the merits and impact of design are clearly illustrated for a clinical audience. 
 
Title Vital Signs App 
Description Demonstration software for a new design of vital signs trolley. The software is able to draw data from a blood pressure cuff, and integrate this with other vital signs to generate a Modified Early Warning Score. 
Type Of Technology Webtool/Application 
Year Produced 2010 
Impact The app was realised and demonstrated in three accompanying exhibitions for the DOME project. This formed part of a collaboration with commercial partners Humanscale. 
URL http://www.domeproject.org.uk/outputs.html#Vitalsigns
 
Description Presentation of the DOME project to an audience of senior managers in the UK public sector at a Westminster seminar - J. Myerson 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The seminar was attended by 70 civil servants and focused on 'Creating a More Healthy and Efficient 21st Century Public Sector Workplace'.
Myerson's paper was entitled 'Healthier By Design: Rethinking workplace design as a catalyst for public sector
wellbeing'.

The research, methodology, designs and trial results were published within the team members' respective disciplines, and this work continues. An exhibition of the DOME innovations, entitled Make It Better, went on show at the Royal College of Art in London in September 2011 and then travelled to the Royal College of Surgeons Hunterian Museum in London (January 2012) and the Pontio centre for multidisciplinary design and innovation, Bangor University, North Wales (March 2012, supported by the European Commission).
Year(s) Of Engagement Activity 2010
 
Description What can we learn about patient safety form the oil industry? - Imperial Surgical Symposium 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Talk sparked interest in DOME
Year(s) Of Engagement Activity 2009
 
Description Ageing and medicine: quantity versus quality - Battle of Ideas, organised by Institute of Ideas, Royal College of Art 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact n/a
Year(s) Of Engagement Activity 2010
 
Description BBC News item - The hidden dangers of hospital beds 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Increased awareness of importance of patient safety and DOME

n/a
Year(s) Of Engagement Activity 2012
URL http://www.bbc.co.uk/news/health-16812137
 
Description DOME workshop at Include Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Workshop followed by discussion around the DOME project's themes

Increased understanding of designing out medical error and inclusive design
Year(s) Of Engagement Activity 2009
 
Description Design for Patient Safety at the Helen Hamlyn Centre - Presentation at Interactive Medical Devices Workshop, UCL 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Talk followed by 30 minute discussion on patient safety and design

Further requests for information about the project at the Helen Hamlyn Centre
Year(s) Of Engagement Activity 2009
 
Description Fast CoDesign: Using Good Design To Eliminate Medical Errors 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Increased awareness of design for reducing medical error

n/a
Year(s) Of Engagement Activity 2012
URL http://www.fastcodesign.com/3021303/evidence/using-good-design-to-eliminate-medical-errors
 
Description Healthcare Design for Patient and Staff Safety - Paper at Build Boston Exhibition and Symposium 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Talk sparked questions about DOME and discussion on patient safety

Increased understanding of DOME activity
Year(s) Of Engagement Activity 2008
 
Description Healthier By Design: Rethinking workplace design as a catalyst for public sector wellbeing. Creating a More Healthy and Efficient 21st Century Public Sector Workplace seminar, Westminster, London 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact n/a
Year(s) Of Engagement Activity 2011
 
Description Make It Better Exhibition at Bangor University, 9/3/12 - 18/3/12. Jeremy gave a keynote presentation on 9/3/12 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Talk and discussions

n/a
Year(s) Of Engagement Activity 2011
URL http://www.bangor.ac.uk/bangorsciencefestival2014/events/pontio-keynote-lecture-and-reception-on-the...
 
Description Make It Better- exhibition at the Hunterian Museum, Royal College of Surgeons 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact Increased understanding of DOME project

Increase in information requests
Year(s) Of Engagement Activity 2012
URL http://www.rcseng.ac.uk/museums/hunterian/documents/pdf-museum-events-brochures/HunterianEventsBroch...
 
Description New Scientist: Designs for eradicating medical mistakes 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Increased awareness of importance of designing out medical error

n/a
Year(s) Of Engagement Activity 2012
URL http://www.newscientist.com/blogs/culturelab/2012/02/designs-for-eradicating-medical-mistakes.html
 
Description The Lancet Technology: February, 2012 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact n/a
Year(s) Of Engagement Activity 2012
URL http://www.thelancet.com/pdfs/journals/lancet/PIIS0140673612602554.pdf
 
Description The Problem Comes First - Helen Hamlyn Centre Research Associates Exhibition and Symposium 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Increased understanding of DOME project

Requests for information
Year(s) Of Engagement Activity 2011
URL http://www.hhc.rca.ac.uk/194-4088/all/1/Major-exhibition-for-London-Design-Festival.aspx
 
Description Using the systems approach to design out medical error 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Talk followed by discussion

Unknown
Year(s) Of Engagement Activity 2011