School of Design Module – PD 6002 – Human Factors in Health Systems Background Medical device design and health systems rely heavily on skills and discretion of health care professionals to ensure care is delivered safety. There are many cases internationally where human factors related issues contributed to, or were the primary cause of, failures in medical device design or healthcare systems and resulted in severe personal injuries or mortalities. Objective Identify a medical device or health system level failure that resulted in several personal injuries or mortality of several patients. Case studies on a medical device should focus on an issue that resulted in several cases of personal injuries or mortalities internationally, or certainly across a number of hospitals. In such case do not focus on an individual surgery and patient as the basis of your report, rather the bigger overall picture. If choosing a healthcare systems failure, the case study could be of a systemic issue in a single hospital or across several locations, as long as it is the same fundamental issue. Requirements 1. Provide an outline description of the problem clinically and the number of patients potentially affected from sources in the public domain. 2. Give an overview of the effect of the error on the patients care from your understanding of the problem. 3. Perform a root cause analysis and single out the human factors issues that contributed to the problem. 4. Detail either proposed or already recommended changes to solve the human factors related deficiencies. Give a 15 minute presentation addressing the details above. Also provide a 1,000 word report describing these details. Presentation tips • Aim to use as little text as possible in the actual slides. If there is a lot of text on the slides the audience will tend to read them instead of listening to you. • Use graphics to address the context of the point you want to make, and possibly supplement with text as key point reminders. • If presenting any illustrations/tables, ensure they are clear. • Avoid just reading text line by line from your slides. • If you do not have full sentences on your slides you cannot then read them. Paraphrase! • Practice your presentation out loud beforehand. • Ensure you do not go over time. Case study report Layout your report as per the requirements above. Subdivide the text into paragraphs as appropriate. Graphs and tables are permitted but only if necessary. You can number the sub sections if you wish, but this is not a requirement. Ensure you cite sources for information used in your report as per the referencing guidelines available for this module. • Single line spacing • Font 12, Ideally Calibri or Arial. Grading 20% of the overall module. • Presentation slide clarity and layout as per 4 requirements – 5% • Presentation skills 5% • Case study report – layout and explanation as per the requirements. Clearly well written including references 10%