Patient Safety and Information Technology IT:

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Patient Safety and Information Technology (IT)

• Partners in Patient Care

VeHU 2008 Session 177 Tuesday July 15, 2008 330
PM 500 PM
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HOUSE KEEPING
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HOUSE KEEPING

• This is 1.5 Hour lecture session
• Restrooms are located
• Cell Phones
• Please turn off or change to vibrate
• If you must answer a call, please leave the room.

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HOUSE KEEPING

• Please,
• No questions during the presentation.
• Questions written on the 3X5 card will be
  answered at the conclusion of the presentation.
• For questions not answered,
• the question and the answer will be available on
  the web.

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Faculty

• Office of Information (OI)
• Health Data and Informatics (HDI)
• Patient Safety Office (PSO)
• Toni King, RN, BSN
• Management Analyst
• Joe Lucas
• Management Analyst
• Janine Purcell, M.S.I.E.O.R.
• Cognitive Engineer

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Learning Objectives

• Describe the Health Data and Informatics (HDI)
  Patient Safety Office (PSO) vision, mission, and
  processes.
• List patient safety issues in terms of human
  performance.
• Explain examples of patient safety initiatives.
• Identify the impact of data integrity and
  information management on patient safety.

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Keeping Patients Safe Using IT Do No Harm
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Vision
Veterans Health Administration (VHA) Office of
Information (OI) is committed to providing the
safest, most effective, and highest quality
software systems that support the delivery of
healthcare.
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Mission

• Patient safety is a continuous process that
  needs to be an integral component within
  healthcare delivery systems. Information
  technology has been recognized as a key factor in
  enabling healthcare facilities to have the
  ability to provide accurate and usable
  information to assist clinicians, nurses,
  pharmacists, allied health care professionals and
  other personnel that interact with and provide
  quality care to patients.

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Mission (cont.)

• The OI patient safety program will support the
  development and implementation of software
  application systems that focus towards
  improvement in safe, effective, quality health
  care, such that the following goals have been
  established

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Goals

• Define program objectives supported by personnel
  and budget.
• Incorporate safety principles, using best
  practices such as user centered design based upon
  human factors engineering principles and
  standardized processes as well as incorporating
  usability testing into the development and
  pre-release evaluation process.
• Implement a non-punitive system for reporting
  safety incidents as well as safety concerns with
  an ultimate emphasis on analysis in which to
  focus future development.
• Establish training and teaching programs for
  existing and new staff to establish an
  organizational culture of safety.

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History

• National Center for Patient Safety (NCPS)
• NCPS was established in 1999 to develop and
  nurture a culture of safety throughout the
  Veterans Health Administration. Their goal is the
  nationwide reduction and prevention of harm to
  patients as a result of their care
• OI Health Data Informatics Patient Safety
• In 2002 Office of Information (OI) recognized
  that Information Technology can have an effect on
  patient safety. They established a process to
  ensure that the electronic health record enhances
  patient care.
• In 2005 -Hired full time Director, OI HDI Patient
  Safety who is a liaison between NCPS and OI
• In 2007/ 2008 - Started staffing the OI HDI
  Patient Safety to provide needed expertise and
  support

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Role of OI HDI Patient Safety

• Foster a non-punitive system for reporting safety
  incidents as well as safety concerns with an
  ultimate emphasis on analysis in which to focus
  future development
• Evaluate risk, determine recommended actions
• Communicate necessary notification(s) to
  Veterans Administration Medical Centers

We dont fix the problem, we are A stimulus to
initiate discussion and a facilitator in having a
solution created.
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Human Factors Engineering What it is and How its
helpful
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Learning Objectives

• Brief introduction to human factors principles
• Human performance issues relevant to clinical
  settings

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Human Factors Engineering

User-Centered Design
Designing Systems to fit human capabilities and
limitations AND the tasks that humans perform
in or with that system
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Evolution of Human Factors

• George Washington time and motion study of
  his farm operations
• Frederick Taylor Time and motion studies in
  Industrial Age
• Frank Gilbreth Motion study in surgery
• World War II -- Aviation HF
• The Age of Computers
• Human Computer Interaction (HCI)

Time and motion studies record a chronology
of actions and time to complete those actions.
They are used as a tool for process improvement.
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Why User Centered Design?

• Safety principles early detection of potential
  problems before an adverse event occurs.
• Cost benefits
• allows for changes in User Interface early in
  life cycle, before time and resources have been
  expended.
• increases the chance that the product will better
  meet end users needs.
• Product effectiveness an intuitive user
  interface design will lead to more accurate and
  efficient product use.

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Industry and Legislative Drivers for Human Factors

• AAMI HE74 Human Factors Design Process for
  Medical Devices
• AAMI HE75 Design Principles for Medical
  Devices
• ISO 9241
• Hardware and Software Ergonomic Standard
• ISO 13407
• Human Factors Enhancements to Software
  Development
• Rehabilitation Act Amendments of 1998 (Section
  508)

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Human Systems Model
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Culture
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Environment
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Tools for BCMA
Eyes and Ears Memory Cognition Body
BCMA Software Medication Carts Bar Code
Scanners PYXIS Pill crushers
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Tasks

• Nurse on med pass regenerates missed meds report
  several times during the med pass on the computer
  and checks it onscreen
• By doing this she updates her checklist of
  remaining patients (Situational Awareness)
  Acute Psych 23 patients for that med pass

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A Human Factors Framework

• What do people do?
• Sense
• Perceive/assume/interpret/think
• Store information in memory
• Retrieve information from memory
• Decide how to respond
• Respond

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• MZALB
• ZYP
• JCEFT
• SUWRG
• TPJOM
• XCIDB
• GCUFI
• WOPR
• BGLDA

LAALK OEWSI GCUFI TPJOM JCEFT SUWRG TPJOM XCIDB J
DIEL
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BLUE RED GREEN WHITE BLUE RED YELLOW WHITE YELLOW
RED BLUE WHITE GREEN BLUE RED WHITE YELLOW GREEN
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Automatic Processing Versus Controlled Processing
(Preece, 1994)

• Automatic processes unaffected by memory limits
• fast
• demand minimal attention
• not available to consciousness
• Controlled processes require attention and
  conscious control

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A Human Factors Framework

• What do people do?
• Sense
• Perceive/assume/interpret/think
• Store information in memory
• Retrieve information from memory
• Decide how to respond
• Respond

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Mind as Tool Multi-store Model of Memory
(Preece, 1994)

• Sensory store
• Specific to sense
• vision less than a second
• hearing several seconds
• Working memory
• information actively being worked on
• Millers Magic Number 7 /- 2
• Permanent long term memory

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Designing to improve decision making

• Cognitive aids
• Optimal screen design
• Density
• Layout
• Smart displays
• Consolidating the data needed to make a clinical
  decision
• Checklists, electronic or paper-based

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Speed / Accuracy Tradeoff

• Cognitive speed bumps
• Removal of data field autofill
• Confirmatory or mandatory fields

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Human Memory Model Working Memory (Mayhew, 1992)

• Working memory is where people
• perform calculations
• interpret incoming data
• juggle information as they solve problems
• Sustained attention is required to maintain
  contents of working memory
• Interruptions hasten the degradation of
  information in working memory, especially as
  interruptions become more complex

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Limited resources are a cognitive reality
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Solutions must come from the nursing team

• Vest for Med Pass
• DRUG ROUND IN PROGRESS
• PLEASE DO NOT INTERRUPT AS MISTAKES CAN COST
  LIVES

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A Human Factors Framework

• What do people do?
• Sense
• Perceive / assume / interpret / think
• Store information in memory
• Retrieve information from memory
• Decide how to respond
• Respond
• Interact in a social environment
• Learn (teach and communicate)

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How to respond

• When I say up, everyone raise your hand up as
  quickly as you can
• Then put it right back down as quickly as you can

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Medical Software Example
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Automatic Processing Versus Controlled Processing
(Preece, 1994)

• Automatic processes unaffected by memory limits
• fast
• demand minimal attention
• not available to consciousness
• Controlled processes require attention and
  conscious control
• Automatic processes difficult to unlearn once
  they have become automatic themselves
• function key assignments, consistent screen
  locations

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Volunteer to write instructions

• Starting from
• Jar of Peanut Butter
• Bag of Bread
• Plate and butter knife
• Ending with two slices of bread and peanut butter
  on plate

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Self Disclosure How it Helps
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When Things Go Wrong

• In the report To Err is Human Building a
  Safer Health System, the Institute of Medicine
  estimated that as many as 98,000 hospitalized
  Americans die each yearnot as a result of their
  illness or disease but as a result of errors in
  their care (IOM, 2000)

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When Things Go Wrong (cont.)

• Data inventory is key.listening to the
  people in your administration, talking to your
  administration, talking to focus groups of
  patients and talking to clinicians. The most
  extraordinary question we ever asked our staff
  was, What do you lie awake at night worrying
  about? The list they came up with is massive,
  full of the things that could fail or go wrong.
• James Conway, MS, COO
• Dana-Farber Cancer Institute
• In Reducing Medical Errors, Improving Patient
  Safety Taking the Next Step, Health Leaders
  Roundtable, June 2001.

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Why Report IT Safety issues

• Good for patients and staff
• Learning opportunity
• Improves safety through feedback
• Build organizational memory on what happened and
  why
• Communicate organization concerns about IT issues
• Aids in correcting vulnerabilities

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Role of the OI HDI Patient Safety

• Direct and Indirect Partnerships
• Patients
• Business owners
• NCPS
• Medical Centers
• End Users
• Analysts
• Support staff
• IT specialists

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OI HDI Patient Safety

• Provides a critical look at all issues
• Data analysis
• Interviews - (storytelling)
• Research
• Remedy tickets
• Past Electronic Error and Enhancement Report
  (E3R)
• Clear Quest database
• NCPS (SPOT) database
• Review literature
• Regulatory organizations
• RCA, HFMEA, Focus Groups
• Participate with various workgroups

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Focus on IT Patient Safety

• Reportreportreport
• Engaging senior leadership
• Involve front end users
• Use available Information Technology tools

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What VA Staff Can Do to Promote a Culture of IT
Patient Safety
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Promoting IT Patient Safety

• Engage patients
• Understand how the environment of care can impact
  patient safety
• Look for anomalies and potential problems
• Report IT near misses/close calls
• Improve Communication
• Automate tasks that are likely to cause errors
• Reduce interruptions
• Intervene when problems are detected
• Culture of vigilance

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• Key Learning from the Dana-Farber Cancer
  Institutes 10-Year Patient Safety Journey
  Al-American Society of Clinical Oncology 2006
  Education Book P.617 James Conway et al.

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Sustaining a Culture of IT Patient Safety

• Everyone in your organization needs to know they
  play an important role in patient safety.
• Leadership Support
• Non-punitive Error Reporting

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Solutions Must Include the End User Perspective
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Learning Objectives

• Solutions must include end user perspectives

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Evaluating a Procedure
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Usability evaluation

• Learned intuition and assumptions
• Stereotypes
• Metaphors
• Iterative evaluation with the human processor
  is how to debug

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• What ignites usability?

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What ignites usability?

• Usefulness
• Efficiency
• Ease of learning
• Ease of remembering
• User satisfaction

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How do we increase the usability of our world?
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High level tactics

• Involve end users as early as possible in the
  design of new systems, processes, and tools
• Integrate human factors knowledge into product
  and process design

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Usability Evaluation

• Gathering data about the usability of a design
  or product by a specified group of users for a
  particular activity within a specified
  environment or work context.
• Preece, 1995
• Somebody doing something, somewhere
• 
  

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Human Factors Engineering initiatives in VHA
Information Technology

• CPRS Lab status information display Informed
  Consent software
• CCOW
• BCMA software development and evaluation
• Bar code expansion
• Medication carts
• Human factors education

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Examples of User Evaluations

• Distributed user evaluations (green lights
  assessment)
• Remote user evaluations with telephonic
  interviewing
• Scenario-based usability testing
• Face-to-Face
• Onsite observation and interviewing

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Code Blue Software Prototype

• User workgroup
• Screen design principles
• Terminology
• Icons versus labels
• Usability Evaluation
• Mock code blue
• Real staff
• Script

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Computerized Medication Carts
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Medication cart evaluation

• Published internal Recommendations advocating
  assessment of computerized medication cart
  equipment in the actual work setting using actual
  work tasks
• Steerability is a prime concern and requires
  cart be loaded and steered through actual
  physical environment in actual workflow to
  adequately assess it
• Ergonomic issues such as height adjustability for
  range of staff
• Utility of cart features such as work surface,
  storage capacity, custom accessories
• Challenges arise from government procurement
  cycle and contracting rules

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To recap

• Solutions must include the end user perspective

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Examples of Patient Safety IT Initiatives
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• Improving safety and quality is a team sport.
  The "dream team" consists of the best clinicians,
  the best people in IT, and the best systems that
  integrate them. It won't be easy, but that's the
  ultimate goal of the system we want to create for
  ourselves.
• Dr.
  Carolyn Clancy, M.D., Director, AHRQ

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PSI-07-227

• Issue- Remedy Help Desk220858 11/27/07 The
  wrong drug was filled and dispensed by Parata
  robot for 3 Rxs when VistA HL7 RXD segment sent
  incorrect NDC numbers for the Rxs
• Flagged as PSI on 11/29/2007
• PSO analysis starts 11/29/07
• PSI discussed on the PSWG 12/13/07

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PSI-07-227 (cont.)

• PSI Scored by PSWG
• Severity 1Minor
• 4Catastrophic
• Frequency 3Occasional
• Detectability4remote
• __________________
• Total Score 48

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PSI-07-227 (cont.)

• Scoring guidelines for follow up Actions
• Greater than 24 Solution to address the
  reported risk must be included in first available
  software release. (i.e. a patch must be
  created immediately or a current patch under
  development must be adjusted to include the
  solution)
• If unable to provide a software solution in
  current version, a detailed plan of action must
  be provided. (i.e. inclusion in current
  version would be prohibited due to current
  product architecture, however, a software
  solution can be adapted into future software
  architecture)
• http//vaww.vhaco.va.gov/HDI/oipatientsafety.asp

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PSI-07-227 (cont.)

• Development finds the source of the problem
• Series of meetings to discuss the problem and the
  solution (fix).
• Emergency patch (disable VistA speed renewal
  function) released 4/1/08
• Permanent solution scheduled for release 6/1/08

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Example Two of Patient Safety IT Initiatives
As soon as you see a mistake and don't
fix it, it becomes your mistake.

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Free-text Allergy Issue

• Free-text allergy entries in CPRS do not
  generate automatic drug-allergy order checks
  necessary for effective medication management.
  Patients with a known allergy may be administered
  a medication or served a food product for which
  they could have a severe reaction.

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Free-text Allergy Issue

• In June 2007, a software utility (GMRA429)
  was provided to automate mapping of existing
  free-text patient allergy entries to standard
  entries.

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Free-text Allergy Issue

• Remaining free text allergy entries were either
  too ambiguous to be reliably mapped, or may
  contain multiple reactants.
• Examples
• Misspelled - Penacillin
• Combined items Tylenol with Codeine
• Assorted Other entries - Misc. Molds

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Free-text Allergy Issue
In January 2008 The OI HDI Patient Safety Office
in conjuction with the National Center for
Patient Safety issued a Patient Safety Alert
requiring that the remaining free text allergy
entries be resolved.
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Discuss Impact of Data Integrity on Patient Safety
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Data Integrity

• The causes of medication errors are
  miscommunication, miscalculations,
  workload/staffing problems, interruptions,
  increases in knowledge and technology demands and
  incomplete documentation
• (IOM, 2004b)

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Data Integrity

• Roadmap for charting delivery of care
• Used for decision making and patient response to
  therapy
• Assist as a reference to recall information
  during handoff
• Used for historical information
• Used for performance improvement
• Staff and patient education
• Joint Commission readiness
• Used for litigation

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Documentation

• If it wasnt charted it wasnt done

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Documentation

• Document at the time or soon as possible (Humans
  are good at recognizing, poor at recall)
• Avoid accepting verbal orders without proper
  documentation
• Be vigilant with documentation-use cognitive
  cues, checklist and other job aids to ensure all
  medications and other care are documented in a
  timely manner
• Ensure documentation reflects the time actions
  were carried out

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• Computers and information systems can make
  important fundamental contributions toward
  creation of safe systems through improving access
  to information, reducing reliance on memory,
  increasing vigilance, and contributing to
  standardization of processes.
• 
  Kilbridge and Clasen
• 
  JAMIA, April 2008
• 
  

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Summary

• OI HDI Patient Safety mission, vision and
  possesses
• Patient safety and human performance
• Role of staff in IT patient safety
• Examples of IT patient safety initiatives
• Impact of data integrity and information
  management on patient safety

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Patient-Centric IT Care
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• Thank you for attending this education session
• Please refer question to the OI HDI Patient
  Safety Office team
• via e-mail
• VHA OI HDI Patient Safety
• Have a SAFE and enjoyable stay in Tampa

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Acronyms
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Web Sites - User Centered Design Societies

• Human Factors and Ergonomics Society (HFES)
• http//www.hfes.org/
• The Usability Professionals Association (UPA)
• http//www.upassoc.org/index.html
• ACM-Special Interest Group on Computer-Human
  Interaction (SIGCHI)
• http//sigchi.org/
• Society for Technical Communications (STC)
• http//www.stc.org/chapter_search.asp

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Other Learning Links

• FAA Human Factors ONLINE Training
• http//www.hf.faa.gov/Webtraining/index.htm
• Human Computer Interaction Bibliography
• Extensive Links to academic researchers and other
  human computer interaction resources
• http//www.hcibib.org/education/

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Other Learning Links

• http//www.usableweb.com/
• http//usability.gov/
• http//www.edwardtufte.com/
• http//www.moma.org/exhibitions/2005/safe/
• http//www.idsa.org/IDEA2007/gallery/index.htm

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Bibliography

• Denning, S. (2005). The Leaders Guide to
  Storytelling Mastering the Art and Discipline of
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  Sons, Inc.
• Dumas, J. and Redish, G. (1993). A Practical
  Guide to Usability Testing. Norwood, NJ Ablex.
• Hackos, J and Redish, J. (1998). User and Task
  Analysis for Interface Design. New York John
  Wiley Sons, Inc.
• Kuniavsky, M. (2003). Observing the User
  Experience A Practitioners Guide to User
  Research. San Francisco Morgan Kaufmann.

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Bibliography

• McLaughlin, R. (2003). Hospital Extra
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  Publishers.
• Preece, J., et al. (1994). Human Computer
  Interaction. Boston Addison Wesley.

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Bibliography

• Rogers, E.M. (1995). Diffusion of Innovations.
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• Rubin, J. (1994). Handbook of Usability Testing.
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Bibliography

• Tufte, Edward (1997). Visual Explanation.
  Cheshire, CT Graphics Press.
• Tufte, Edward (1990). Envisioning Information.
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• Tufte, Edward (1983). The Visual Display of
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