Workshop on

Human Error and Clinical Systems

15-17th April 1999, The Senate Room, University of Glasgow.


Wednesday 14th April

        Welcome reception
        Department of Computing Science, University of Glasgow.

Thursday 15th April

        Introduction, Chris Johnson.

        Keynote: The "Why" of Error in Clinical Systems
        Marilyn Sue Bogner, Institute for the Study of Medical Error,
        Bethesda, USA.


        Session 1: Improving Medical Incident Reporting
        Chair: Tjerk van der Schaaf,
        Safety Management Group, Technical Univ. of Eindhoven.

        Critical Incident Reporting in Anaesthesiology in Switzerland Using
        Standard Internet Technology
        S. Staender, M. Kaufman and D. Scheidegger, Dept. of Anaesthesia,
        Univ. of Basel.

        Risk Oriented Data Capture: Staged Modelling and Sample Solutions
        with Data Overload in Clinical Settings
        J. Arthur and H. Wynn, The Risk Initiative, Warwick University.

        Towards the Identification of Prototypical Risk Situations in
        A.S. Nyssen, Psychologie du Travail, Universite de Liege.


        Paper Session 2: Interface Design and Evaluation
        Chair: Martin Gardner, University of Glasgow.

        Improving the User Interface to Increase Patient Throughput
        A. Gupta, J. Masthoff and P. Zwart,
        Philips Research Laboratories, Redhill.
        Philips Medical Systems, Brest, Netherlands.

        Problems Caused by Human Error in the Operation of a Clinical
        Data Collection System
        Barbara McManus, Department of Health Informatics,
        Univ. of Central Lancashire.


        Paper Session 3: Diagnosis and Treatment Support Tools
        Chair: John Gosbee, Applied Medical Informatics,
        Michigan State University.

        Safety and Computer Aided Design of Chemotherapy Plans
        P. Hammond, S. Modgil and J.C. Wyatt,
        Department of Informatics, Eastman Dental Health Institute and
        Health Knowledge Management Centre, University College London.

        Computer-Aided Mammography: A Case Study of Error Managment in a
        Skilled Decision Making Task
        M. Hartswood and R. Procter,
        Inst. of Communicating and Collaborating Systems, Edinburgh University.

Friday, 16th April

        Session 4: Longitudinal Studies
        Chair: Tjerk van der Schaaf, Safety Management Group,
        Technical Univ. of Eindhoven

        Ten Years of a Medical Incident Reporting System (provisional title)
        David Wright, Intensive Therapy Unit,
        Western General Hospital, Edinburgh.

        Identification & Analysis of Incidents in Complex, Medical Environments
        Daniela Busse and Chris Johnson, Dept. of Computing Science,
        Univ. of Glasgow.


        Session 5: Learning from Medical Risk Analysis
        Chair: Daniela Busse, University of Glasgow

        Moving from Industry/Transportation to the Medical Domain
        Tjerk van der Schaaf, Safety Management Group,
        Technical Univ. of Eindhoven.

        Application of a System Model to Obstetric and Neonatal Audit
        J. Davies, Foothills Medical Centre, University of Calgary.

        Teaching about Error in Health Care
        John Gosbee, Centre for Applied Medical Informatics,
        Michigan State University.


        Session 6: Ethnography and Workplace Studies
        Chair: Anne-Sophie Nyssen, Psychologie du Travail, Universite de Liege

        Fragmentation in Care and the Potential for Human Error
        A. Shepherd and O. Kostopoulou,
        Cognitive and Ergonomics Research Group, Loughborough University.

        Human Error in the Context of Work Activity Systems
        M. Harris, A.P. Jagodzinski, K.R. Greene
        Perinatal Research Group, Derriford Hospital.
        Postgraduate Medical School, School of Computing, Univ. of Plymouth,


        Keynote: Works in Theory but not in Practice? Some notes on the
        Precautionary Principle
        Sir Kenneth Calman and Denis Smith,
        Centre for Risk and Crisis Management, Durham University.

        Close and hand-over

Saturday, 17th April
        This will provide the opportunity for informal discussions about
        the issues raised during the workshop.   This day will be spent on
        the Isle of Arran, off the west Coast of Scotland.

For any further details contact:

        Prof. Chris Johnson,
        Department of Computer Science,
        University of Glasgow,
        Glasgow, G12 8QJ,

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        tel.:    +44 141 330 6053
        fax.:    +44 141 330 4913