Initial observations and mapping

Members of the DOME team including designers, clinicians, psychologists and ergonomists carried out several hundred hours of initial observations in three hospitals in order to observe all activities that patients and staff participate in. Immersing themselves in the hospital environment meant they were able to investigate the full range of factors contributing to medical errors. The research team began by observing the surgical patient journey through the hospital and visualised this using mapping techniques.


Exploring the problem

A comprehensive literature review of all published adverse events revealed that the surgical ward was as hazardous as the operating theatre, but the review did not identify the most important sources of error or explain why harm was occurring. Therefore patients and staff participated in a risk assessment survey to determine which healthcare activities were most hazardous. The five most hazardous healthcare activities on surgical wards were identified and prioritised. Detailed observations and in-depth interviews with patients and healthcare staff allowed these five healthcare activities to be fully understood and mapped. The five highest-risk processes that occur in and around the patient’s bed were hand hygiene, information hand-over, vital signs monitoring, isolation of infection and medication delivery.

Prioritisation of risks

The five healthcare processes that were rated as high risk in the survey were subjected to an engineering design technique called Failure Mode and Effects Analysis (FMEA). Expert groups consisting of doctors, nurses, patients and researchers, all with experience of the subject matter, were organised by the DOME team to validate the healthcare process maps and then rate the risk associated with each step in the processes. Steps in each process that were associated with the most risk were carried forward to the next stage.

FMEA Workshop

Cause Analysis

The riskiest steps in each healthcare process were assessed using the framework for analysing risk and safety in clinical medicine. The expert groups were asked to give the reasons why each type of failure may occur and continue giving reasons until the systemic weaknesses of the system were identified. This allowed the causes associated with the highest risk failures in the entire surgical ward environment to be identified and targeted for patient safety improvement.

Analogous Industries

Concurrent with the research on surgical wards, the DOME project investigated how risk is managed and safety considered in other industries. Members of the team visited international sites in the mining, chemical, oil exploration, shipping and construction industries to draw lessons on ways to reduce systemic error. Process maps were created for analogous industry processes to sit alongside the surgical pathway maps. Task design, reminders, equipment and space were identified as generic components in any design-led approach to improving safety. This work was combined with a review of operations management literature in the field, including key models for managing complexity such as Reason’s Swiss Cheese model (2000), which was expanded to develop a healthcare error proliferation model.

PPE clothing on site

Arriving at design briefs

An understanding of errors, their causes and methods to manage risk was central in shaping the design briefs that would direct the eventual project results. A rich and detailed picture of where and why errors occur was built up during the research, and major systemic weaknesses became apparent. This broad learning was combined with the original focus on healthcare processes so that each process formed the centrepiece of a brief. The designs detailed on this website are responses to each of these briefs.