Reducing 'User Error:' U.Va. Engineer Developing Safer, More Effective Systems for High-Risk Industries

October 17, 2008

October 16, 2008 — Working in a complex system such as an inpatient hospital ward can be a dizzying experience. And when the flow of information from patients to caregivers to electronic medical records breaks down, patients can receive incorrect medications and surgeons can operate on the wrong body part.

Stephanie Guerlain, an associate engineering professor at the University of Virginia, is using cognitive engineering to streamline complex systems. Her work aims to create a less stressful workplace for system operators and, in turn, a safer world for the public.

“Having effective support systems makes workers using such systems happier, more productive and less likely to make errors,” said Guerlain, a member of the Department of Systems and Information Engineering in the School of Engineering and Applied Science. “This can help operators avoid accidents that could otherwise have a large, negative public impact.”

In late September, Guerlain presented her lecture on this field of research, “Cognitive Engineering: It’s Not What You Think,” at the 2008 Frontiers of Engineering Symposium, hosted by the National Academy of Engineering in Albuquerque, N.M.

A combination of psychology, anthropology, computer science, design and systems engineering, the field of cognitive systems engineering is the understanding and designing of systems that require human intellectual work. In addition to Guerlain’s design of systems for medical, power and military applications, her research could be applied to improving the design of air traffic control and financial monitoring systems.

Guerlain designs software that provides users flexible and easy-to-use data visualization tools with direct access to details and the ability to annotate displays or communicate key findings. These improvements would take the place of operators relying on their memory or using ad hoc methods to deal with a given problem.

She also analyzes products and workspaces for usability flaws, also known as “use hazards.” These are features in a product or workspace that make certain kinds of use errors likely to happen, such as the close placement of two look-alike buttons or an excessive number of steps required to accomplish a task. She then works with manufacturers to eliminate these flaws.

In a paper summarizing her research and the importance of improving human-system interfaces, Guerlain gives the example of a highly trained crew flying a perfectly functioning plane into the side of a mountain — a situation common enough to warrant its own acronym, CFIT, which stands for “Controlled Flight Into Terrain.”

“In many cases, there is no mechanical failure. The computers and other automation processes work as designed,” Guerlain noted, “so accidents in these situations are commonly labeled as ‘human error.’”
But, by studying people’s day-to-day activities, she finds that many systems are just not designed well to begin with from a cognitive engineering perspective. In other words, they do not “fit” with what we already know about how humans think, process information and make decisions given task constraints and contexts of use.

Guerlain’s presentation at the Frontiers of Engineering conference was not only a chance to showcase her work in cognitive engineering, but also to learn from other presenters. This year’s conference brought together some of the nation’s leading engineers to discuss emerging nanoelectronic devices, cognitive engineering, drug delivery systems and understanding and countering the proliferation of weapons of mass destruction.

“It is an honor to be invited to speak at the National Academy of Engineering,” Guerlain said. “It’s also very exciting to learn about other leading-edge engineering topics from rising-star engineers throughout the country.”

In addition to presenting at this year’s conference, Guerlain also has been asked to organize a presentation on medical informatics for next year’s Frontiers of Engineering conference.

— By Zak Richards