Anne van Dalen

4 Analyzing and discussing human factors affecting surgical patient safety I 147 Desirable feature missing Laparoscopic tool/instrumentation does not possess function/feature that would be valuable/useful to user Notification system lacking Absence of notification to user in the event of setup error/ technological malfunction/ improper use Safety/ Reliability Issues Unintended effects Proper use of tool results in unintended effects (Ex. Thermal spread of energy device is abnormally/unexpectedly high despite proper use/setting) Dangerous design elements Elements of the tool/equipment design have the potential to place patient safety at risk Inconsistent functionality Standard use of tool/tech produces inconsistent results Not robust Tool design does not sufficiently protected against use error; tool/tech design allows for unintentional/accidental deployment of undesired functions; easy to mess up Tool/task mismatch Available tool is incompatible with/inappropriate for the task at hand Workarounds/ improvisation Clinicians rely on workarounds to bypass usability problems/achieve desired goals Usability Issues Tech instructions unclear Instructions for using equipment/ error messages are confusing/not easily interpreted Instrument differences Differences/inconsistencies between the designs of the laparoscopic instrumentsforce userstochange/adapttheirsurgical approachwitheach change in instrument