The CDC should consider having "Human Factor Engineers" examine their Ebola protocols.
To determine how well actual human beings (not robots) can follow them in real-life situations.
Any protocol is only as good as the human beings that have to carry it out.
http://psnet.ahrq.gov/primer.aspx?primerID=20
An obstetric nurse connects a bag of pain medication intended for an epidural catheter to the mother's intravenous (IV) line, resulting in a fatal cardiac arrest. Newborns in a neonatal intensive care unit are given full-dose heparin instead of low-dose flushes, leading to three deaths from intracranial bleeding. An elderly man experiences cardiac arrest while hospitalized, but when the code blue team arrives, they are unable to administer a potentially life-saving shock because the defibrillator pads and the defibrillator itself cannot be physically connected.
Busy health care workers rely on equipment to carry out life-saving interventions, with the underlying assumption that technology will improve outcomes. But as these examples illustrate, the interaction between workers, the equipment, and their environment can actually increase the risk of disastrous errors. Each of these safety hazards ultimately was attributed to a relatively simple, yet overlooked problem with equipment design. The bag of epidural anesthetic was similar in size and shape to IV medication bags, and, crucially, the same catheter could access both types of bags. Full-dose and prophylactic-dose heparin vials appear virtually identical, and both concentrations are routinely stocked in automated dispensers at the point of care. Multiple brands of defibrillators exist that differ in physical appearance as well as functionality; a typical hospital may have many different models scattered around the building, sometimes even on the same unit.
Human factors engineering is the discipline that attempts to identify and address these issues. It is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use. A human factors engineer examines a particular activity in terms of its component tasks, and then assesses the physical demands, skill demands, mental workload, team dynamics, aspects of the work environment (e.g., adequate lighting, limited noise, or other distractions), and device design required to complete the task optimally. In essence, human factors engineering focuses on how systems work in actual practice, with real—and fallible—human beings at the controls, and attempts to design systems that optimize safety and minimize the risk of error in complex environments.
Human factors engineering has long been used to improve safety in many industries outside of health care—it has been employed to analyze errors in aviation, automobiles, and the Three Mile Island nuclear power plant accident. Its application to health care is relatively recent; pioneering studies of human factors in anesthesia were integral to the redesign of anesthesia equipment, significantly reducing the risk of injury or death in the operating room.
SNIP
= new reply since forum marked as read
Anyone who believes donning and removing the appropriate safety gear should spend some time changing diapers using universal precautions - preferably on an adult who is difficult to move with diarrhea (or a very squirmy 2 year old) marked with dye that is visible only in special lighting. My bet is that well over 90% of individuals who try it - including medical personnel - contaminate either the exterior of diaperee's clothing OR the hands/clothing of the person doing the diapering.
I do this on a semi-regular basis, and although it is not rocket science - it is extremely hard to do correctly - both because of the squirm/manageability factor - and the need to develop a physical memory of which layer of gloves has touched clean v. dirty.
