Designing Out Medical Error is a three-year multidisciplinary research and design project. A team of designers, clinicians, psychologists and patient safety experts was brought together to look at the problem of medical error on elective surgical wards. The aim was to understand common healthcare processes, where they fail, and identify where design can intervene to reduce errors. The team worked collaboratively to co-research and co-design solutions with front line staff, and later with manufacturers to produce a suite of five designs for the hospital ward. These have been clinically trialled and one output is now in use in the UK.

The problem we set out to address is the unacceptably high rates of medical error in hospitals. Medical error is never far from the headlines, and is often a hot political topic. International research has shown that in up to 10% of hospital admissions, patients suffer some form of harm as a result of errors in their care. Whilst improved training and standards have a role to play, they do not represent the entire solution. Modern healthcare is a complex combination of technology and processes, and the typical hospital ward has a variety of equipment and devices, often poorly integrated. As healthcare practice has developed, often the supporting equipment has not kept pace. As a result, many common healthcare processes are not well supported by design, and clinicians must constantly make allowances for poor equipment and interfaces.

The challenge was to understand and map typical healthcare processes and discover where errors occurred, as well as their causes. By thoroughly understanding these common processes, areas of design intervention could be identified. The brief was to identify these areas where design could make a difference, and produce detailed specifications and performance requirements for common ward equipment. These requirements were to be realized as physical designs embodying the underlying research, placing the end user’s needs at the heart of the design process.

The project involved a unique research collaboration between clinicians and designers. The clinicians in the team were involved in the design work, and the designers spent a large amount of time on hospital wards during the clinical research. The multidisciplinary approach allowed a constant clinical viewpoint on design, and an opportunity for a fresh look at clinical processes by the designers. This enabled fundamental questioning of basic healthcare processes by all members of the team.

The broad brief was extended to include the refining and testing of design work in order to validate the methodology. Taking the outputs further, the project aimed to achieve the gold standard of clinical research – a translational outcome to influence front line clinical practice.

Additional criteria added to the initial brief helped to further refine and focus the research and subsequent design work. Extensive research in the clinical environment led to the formation of five ‘sub-briefs’, tackling more specific processes: medication administration, hand hygiene, the measurement of vital signs (such as temperature and blood pressure), infection control precautions and staff handover. This allowed the design work to be built on direct insights from the front line, and tackling the five briefs simultaneously allowed a detailed picture to be built up of the hospital ward and associated processes. This holistic view aimed to reduce the introduction of new errors with any new design intervention by understanding the context of use.

The first year of the project was spent doing rigorous clinical research, understanding the broader context of the hospital system surrounding the surgical ward. Patients were shadowed through their journey from admission to discharge, mapping out the systems, processes, equipment and people encountered during the stay. Further detailed observations and interviews were carried out, focusing on common healthcare processes and resulting in a series of five detailed process maps. These were verified with system experts during interview, and ways in which each step in the process could go wrong were described. A Failure Mode and Effects Analysis (FMEA - a technique borrowed from high risk industry) was then performed on each one. A small group consisting of a patient, a doctor, a nurse and a process expert went through each map and considered the failure modes, scoring them for severity, frequency and detectability. This revealed certain ‘hotspots’ of error in each process. The causes of these errors were explored in further expert interviews (using a defined causal analysis method). The combination of process maps, error points and their causes provided invaluable detail for each ‘sub-brief’.

These brief were written collaboratively with clinical staff, and checked with the process experts. They were critical in capturing the information coming out of the research, but had to be broad enough to allow the generation of a range of concepts. The briefs were corroborated with further front line observations to check that the design issues were experienced by a variety of healthcare workers.

Once the briefs were set, the clinical staff were encouraged to take part in a series of co-design workshops with the designers to generate a range of ideas to tackle each brief. This ensured that the interests of the primary stakeholders (the healthcare professionals) were at the heart of the design work. This user group was consulted throughout the design process, involving over a hundred staff across three different large teaching hospitals.

From the creative phase, the project moved into the critical refinement of ideas through clinical feedback. Again, visiting staff and patients on hospital wards helped to ensure that the design work remained relevant. Early and rough prototyping was a valuable tool in getting feedback and in iteratively refining the ideas.

As the project progressed, the designs became more detailed and the prototypes were more resolved. A ‘simulation’ ward was set up to recreate the features of a regular surgical ward, and the prototypes were placed in the space. Nurses were given specific tasks to perform, once with the new designs, and once without (order randomised). Their actions were filmed for link analyses, further informing design development.

More extended clinical trials of some of the designs are ongoing. One output of the project, a new item of ward equipment, is in trials across the UK, and is fully manufactured and available for purchase.

Costs, materials and impact on personnel were considered in close liaison with manufacturers, front line clinicians and representatives of UK NHS purchasing and policy.

The project has resulted in a direct change in ward processes. The five outputs of the brief are at various stages of development, but the more resolved ideas are currently in clinical trials, and one is now available for purchase. This design is the ‘CareCentre’, an all-in-one unit for the end of the hospital bed, containing equipment for common bedside tasks. It is now in use across the country, and feedback from users has been very positive, improving access to equipment and increasing efficiency. The aim is to improve compliance with correct procedures and thereby reduce errors and infections. Full clinical trials gathering evidence for this are ongoing, and initial findings are positive.

By taking a research solution through to manufactured product, the project has also had a direct economic impact on UK industry, benefiting manufacturers by opening up a new market. The manufacturer was chosen for their sound environmental standards and policies. The broader aim to improve patient safety has the added environmental impact of reducing waste through a reduction in avoidable complications and in the length of stay.

The broader impact of the project is the dissemination of the methodology. The working methods and multidisciplinary approach of the project have been widely published in academic journals, conferences, three dedicated exhibitions and the national press. The impact on both the design and clinical communities is shown by the raising of awareness of the role design has to play in reducing medical error; numerous similar projects are planned.

The initial remit of the project was deliberately very broad, with no solutions or pre-conceived designs. The aim was to look at the problem of medical error from a completely fresh starting point. However, as the research progressed and the focus became more specific, it became clear that there were cultural differences within the multidisciplinary team which needed to be addressed. A shared platform had to be agreed upon, and this was the focus on the space immediately around the patient’s bed. In addition, it was necessary to have a very clear working method which all parties understood. This led to the adoption of the FMEA tool, which clearly defined the team roles.

The context of the hospital ward is in constant flux; the team had to keep abreast of emerging research and best practice on the ward. Throughout the course of the project, the focus became more tightly defined, and the final issues under consideration were very specific (e.g. reminders for hand hygiene, the writing of patient information etc). The challenge was to view these narrow focuses within the broader context of the overall project aims. By designing to five related briefs simultaneously, an understanding of specific and systemic problems was built up.

The result was a suite of solutions tackling practical problems, but contributing to a systems level view of the overarching issue of patient safety.