<XML><RECORDS><RECORD><REFERENCE_TYPE>31</REFERENCE_TYPE><REFNUM>7270</REFNUM><AUTHORS><AUTHOR>Johnson,C.W.</AUTHOR></AUTHORS><YEAR>2003</YEAR><TITLE>The Interaction Between Safety Culture and Uncertainty over Device Behaviour: The Limitations and Hazards of Telemedicine</TITLE><PLACE_PUBLISHED>In G. Einarrson and B. Fletcher (eds), International Systems Safety Conference 2003, </PLACE_PUBLISHED><PUBLISHER>Dept of Computing Science, University of Glasgow</PUBLISHER><PAGES>273 - 283</PAGES><ISBN>0-9721385-2-8</ISBN><LABEL>Johnson:2003:7270</LABEL><KEYWORDS><KEYWORD>Human Factors</KEYWORD></KEYWORDS<ABSTRACT>The introduction of new technology carries with it a degree of uncertainty on the part of system operators. They must match device behaviour to the operating characteristics described during training sessions or within supporting documentation. When operators are uncertain about what their system is actually doing then they frequently resort to coping strategies. This threatens patient safety in many healthcare applications. For example, clinicians often reboot monitoring systems in order to return to a recognized state. This creates problems if the device is left in an inconsistent state on power-up or if critical data is lost when the device is restarted. Conversely, when manufacturers receive reports about adverse events, they often find it difficult to reproduce the error conditions that are described by clinicians and healthcare technicians. These problems are exacerbated when end-users do not fully understand the technologies that they are using. This paper argues that such uncertainty threatens the introduction of ‘telemedicine’. We are interested in this class of applications because incident reporting systems are beginning to document a growing number of adverse events that stem from the distributed monitoring and treatment of large numbers of patients. The following pages illustrate this argument using reports submitted to the Food and Drugs Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database over the last twelve months. These incidents show that uncertainty about device behaviour can undermine attempts to establish a new ‘safety culture’ based on communication between clinicians, technician and device manufacturers. </ABSTRACT><NOTES>Published by the International Systems Safety Society</NOTES></RECORD></RECORDS></XML>