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Adverse events reports

CtL lab Presentation


Mode Error

Electronic device interfaces may be designed to minimize the number of control keys, as a way to keep costs down. Changing the meaning of each key by providing different contexts (modes) is one way to provide a broader range of control options. When devices have different modes of operation, an action that is appropriate for one mode has a different meaning in another mode. For example, “1:00” on an electronic alarm clock can mean "the time now is 1:00" or "you will wake up at 1:00" depending on the mode the user chooses. Infusion devices use mode switching to increase the functions available for a small set of control keys. The examples shown here demonstrate how modes can also induce what is referred to as “mode error” in which changed meaning in the same context leads to an incorrect action. A clinician who enters a program for a drug in one mode (loading mode) when they intended to program it in another (infusion mode) will get an entirely different result, as a loading dose infuses much faster. The difference can have significant clinical outcomes for a patient. We describe ways to manage this aspect of infusion device design, so that mode error might play less of a role in device programming.


- Cook RI, Woods DD [1996] Implications of Automation Surprises in Aviation for TIVA Journal of Clinical Anesthesia. 8(3 Suppl): 29S-37S. (582)

 
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