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Jt Comm J Qual Saf. 2004 Oct;30(10):579-84.

Poor interface design and lack of usability testing facilitate medical error.

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Department of Emergency Medicine, University of Rochester School of Medicine, New York, USA.



A fictional scenario based on a compilation of several real events describes seven medical errors that at first appear to be caused by the paramedics and nurses involved.


An emergency medical services paramedic attempted to use a debrillator on a 67-year-old man with ventricular tachycardia Yet nothing happened. The defibrillator displayed an indication that it was in synchronized mode but provided no feedback to tell the user that it was not prepared to shock because of low QRS amplitude. USABILITY TESTING: A hands-on approach to discovering the difficulties and potential for error that people encounter when trying to use a product, usability testing can help to create medical devices and systems that are not only more "user friendly" and efficient-but safer.


Recommendations are presented to enable health care leaders to apply human factors considerations in their product evaluation and purchasing decisions. Medical device manufacturers should involve human factors engineers in the design process from the outset and should perform usability testing. Health care organizations should expect an optimized and tested user interface in the medical devices they purchase.


Many adverse events in medicine are the result of poor interface design rather than human error. The HFE concepts of usability and standardization are critical to patient safety.

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