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Pete Doyle
Hopkins’ first human factors engineer studies how we interact with machines—and other people—to reduce the likelihood of errors.


Have you ever tried to push a door open—even when pull appeared above the handle? Or turned on cold water when you thought you’d get hot? Intuition often guides how we use devices, yet sometimes they work counterintuitively. In health care, poorly designed equipment can contribute to patient harm.

Enter Pete Doyle, Hopkins Hospital’s first human factors engineer, one of only a few in the nation affiliated with a hospital. A member of Clinical Engineering Services, he’s working to make medical devices and the people operating them more error-proof.

A discipline that’s roughly 60 years old, human factors engineering examines human abilities and limitations and uses that knowledge to design systems to be easier and safer to operate. The field got its start during World War II, when poor cockpit design often led to pilot error and sometimes to crashes. The new specialty addressed these problems, so pilots could more easily assimilate flight information and use controls properly.

In health care, the goal is similar: to adjust equipment and processes to fit users, not the other way around, explains Doyle. “We used to call it human error,” he says, “but the problem is often induced by system design. We want to make sure that devices not only work, but that they can be used safely.”

From the moment he arrives at work, Doyle’s on the prowl with a notebook, watching how employees interact with machines and each other. Following human factors methodologies, he examines devices, checks to see if controls and displays are set up in a logical manner, if the menus are easy to navigate and if labels and instructions are clear. He identifies hazards that may occur during use or maintenance and looks for preventive controls.

Infusion devices, for example, should have design features that keep air from being injected into blood vessels. One product uses a clamp on the fluid tube to accomplish this, but if power is interrupted, the clamp lifts and air can enter the bloodstream. Other pumps have problems with how information is displayed. 

And, as devices become more complex, says clinical engineering director Andrew Currie, the human aspect becomes more pivotal. “So much of our success depends on human performance and how we interface with equipment,” he says. “A growing body of research on this topic convinced me and others on the Patient Safety Committee that hiring a human factors engineer made sense.” Doyle, he adds, has unique training to weed out potential problems with technology and system design, taking into account our intuitive responses. “Pete is also creating scenarios to test those core issues,” says Currie, “which has been invaluable in training staff.”  

Doyle assesses each device in context. He might observe how people interact with equipment in realistic scenarios, using Hopkins’ “Sim Man” as the patient. As he watches participants work on this mannequin during lifelike codes or other events, Doyle identifies opportunities for mishaps. He then solicits additional input from among the four clinical engineers and 31 technicians based in Brady 104, under Currie’s direction.

But Doyle’s radar for potential mistakes extends way beyond the device. Equally important—and usually harder to pinpoint, he says—are breakdowns that occur when we misinterpret each other’s spoken or written communication. 

To close those gaps, Doyle analyzes steps to accomplish tasks and identifies conditions—including factors like sleep deprivation or staff shortages—that promote error. While observing how surgical specimens are collected and evaluated, for example, he identified 30 steps to get the specimens labeled, packaged and sent to Pathology. Then he witnessed and analyzed even more steps involved in preparing the frozen section. He thought the process could be streamlined. “Our goal,” says Doyle, “is to reduce the possibility of labeling errors that could result in incorrect diagnoses.” 

A Baltimore native with a Ph.D. in applied experimental psychology, Doyle began his career redesigning nuclear power plant control rooms in the wake of Pennsylvania’s Three Mile Island nuclear accident in 1979. After 17 years in the defense industry, he joined the communications field, where he tested Web sites and cell phones. A year ago, he signed on with Hopkins.

With the advent of two new clinical buildings, Doyle’s workload is increasing daily. He’s helping to determine the needs of Surgery, Radiology, Nursing, Pathology and other departments for the design of the visual and information systems in the new operating rooms. “Our goal is to facilitate integration and control of all relevant patient and scheduling information for many different users,” says Doyle. “I strive to aid in the design of systems and tasks that are easily learned, memorable, error-free and efficient.”

— Judy Minkove

Doyle encourages anyone observing what might be an equipment or process-related safety issue to call him at 410-955-2100, ext. 156.        



Johns Hopkins Medicine

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