An Action-based Hierarchical Task Analysis for Evaluating Medical Device Safety

Since the release of the Institute of Medicine medical error report in 1999, human errors in medicine and patient safety have become of great concern in the medical field. Device level incidents stemming from poorly designed interfaces are becoming particularly problematic, with advances in device technology. This is not, however, a new problem. The literature has long suggested that the number of injuries resulting from these types of problems far exceed that of injuries due to actual device failures (Cooper, Newbower, Long, & McPeek, 1978). Hence, the motivation for this effort was to apply existing cognitive theory to evaluate the safety of a simple yet pervasive medical device, the volumetric infusion pump.