Presentation
Pressing Issues: Addressing False Codes Triggered From Touchscreen Terminals
DescriptionNew and evolving technologies are implemented in healthcare to enhance patient outcomes, communication, and overall efficiency. However, the introduction of new systems can introduce unintended issues. Mount Sinai Hospital (Sinai Health System) in Toronto, Canada, has been undergoing significant redevelopment and expansion of many of its clinical units, which has involved the rollout of various new and updated technologies, including an updated Nurse Call System. This systems, comprising several interconnected components, is designed to enable staff to trigger alerts for various needs, such as codes, room cleaning, or additional nursing support.
Since updating the system, the Emergency Department (ED) reported a troubling increase in false codes and alerts. This led to staff frustration and a decline in nursing response rates to codes due to alert fatigue. To address the issue, the hospital’s Human Factors team was engaged by the ED to investigate and provide mitigation strategies.
Organizational data from the hospital’s Locating and Switchboard department was leveraged to assess the extent of the issue and identify patterns in the false alerts. Approximately 44% of the announced codes in the ED were found to be attributed to false alerts. The primary source was identified as accidental presses of buttons on the newly implemented touchscreen Nurse Call terminals in patient rooms. These terminals can be programmed based on unit-specific communication needs, displaying buttons that alert particular staff roles or the code types likely to be called on a unit. Further analysis indicated that accidental presses often stemmed from support staff inadvertently hitting code buttons, while other causes—such as staff or patients bumping into the terminals, and visitors tampering with the screens—were less common.
To gain deeper insights, observations of support staff workflows and interactions were conducted, and a heuristic assessment of the touchscreen terminals was performed. Contributing factors and mitigation strategies were identified and discussed with ED leadership. Mitigations included, updating the terminal button layout, adding protective plastic screen covers, implementing passcode access for the screen, introducing a blank “buffer” screen, or even completely removing code buttons from the terminals. Human factors strongly supported the updated layout solution as the investigation had identified the existing layout did not align with support staff workflows during room turnover. Other proposed mitigations involved significant costs or risked introducing new safety and usability issues, which needed careful consideration against the benefit of addressing the false alerts. Ultimately, leadership supported human factors going forward with the layout change, and assessing the need for additional mitigations after its implementation.
Revised layout designs were developed based on comprehension of the different user group workflows and usability principles. Paper mock-ups were presented to ED clinical and support staff during huddles and hallway feedback discussions. The design was iterated upon and the final version implemented within all ED patient rooms. While quantitative data on the impact of the change is still pending, anecdotal evidence from ED leadership suggests a noticeable decrease in false alert occurrences following the layout change. As a result, they have decided to hold off pursuing any additional mitigations at this time.
Despite best intentions, new technology does not always initially deliver on the anticipated benefits and can sometimes introduce new challenges for staff. The case concretely demonstrates how insights from Human Factors should play a vital role in implementing new technologies into healthcare, ensuring that innovations enhance rather than hinder the processes they are meant to improve.
Since updating the system, the Emergency Department (ED) reported a troubling increase in false codes and alerts. This led to staff frustration and a decline in nursing response rates to codes due to alert fatigue. To address the issue, the hospital’s Human Factors team was engaged by the ED to investigate and provide mitigation strategies.
Organizational data from the hospital’s Locating and Switchboard department was leveraged to assess the extent of the issue and identify patterns in the false alerts. Approximately 44% of the announced codes in the ED were found to be attributed to false alerts. The primary source was identified as accidental presses of buttons on the newly implemented touchscreen Nurse Call terminals in patient rooms. These terminals can be programmed based on unit-specific communication needs, displaying buttons that alert particular staff roles or the code types likely to be called on a unit. Further analysis indicated that accidental presses often stemmed from support staff inadvertently hitting code buttons, while other causes—such as staff or patients bumping into the terminals, and visitors tampering with the screens—were less common.
To gain deeper insights, observations of support staff workflows and interactions were conducted, and a heuristic assessment of the touchscreen terminals was performed. Contributing factors and mitigation strategies were identified and discussed with ED leadership. Mitigations included, updating the terminal button layout, adding protective plastic screen covers, implementing passcode access for the screen, introducing a blank “buffer” screen, or even completely removing code buttons from the terminals. Human factors strongly supported the updated layout solution as the investigation had identified the existing layout did not align with support staff workflows during room turnover. Other proposed mitigations involved significant costs or risked introducing new safety and usability issues, which needed careful consideration against the benefit of addressing the false alerts. Ultimately, leadership supported human factors going forward with the layout change, and assessing the need for additional mitigations after its implementation.
Revised layout designs were developed based on comprehension of the different user group workflows and usability principles. Paper mock-ups were presented to ED clinical and support staff during huddles and hallway feedback discussions. The design was iterated upon and the final version implemented within all ED patient rooms. While quantitative data on the impact of the change is still pending, anecdotal evidence from ED leadership suggests a noticeable decrease in false alert occurrences following the layout change. As a result, they have decided to hold off pursuing any additional mitigations at this time.
Despite best intentions, new technology does not always initially deliver on the anticipated benefits and can sometimes introduce new challenges for staff. The case concretely demonstrates how insights from Human Factors should play a vital role in implementing new technologies into healthcare, ensuring that innovations enhance rather than hinder the processes they are meant to improve.
Event Type
Oral Presentations
TimeWednesday, April 29:37am - 10:00am EDT
LocationHarbour C
Hospital Environments (HE)