Practice-Centered Design of an Anesthesia Medication Template to Reduce Medication Handling Errors in the Operating Room

Axel Roesler, Eliot B. Grigg, Lizabeth D. Martin, Faith J. Ross, Magnus Feil, Sally E. Rampersad, Charles M. Haberkern, Lynn D. Martin

This case study examines the design process of the Anesthesia Medication Template (AMT), a low cost, standardized layout template for the staging and identification of syringes on top of the anesthesia cart in the hospital operating room. The project was conducted in a participatory design framework as co-design between physicians and designers. Led by anesthesiologists and immersed in the work setting as practice-centered design, design development addresses individual, environmental and organizational aspects of the hospital as high-stakes work setting. The layout of the AMT was developed based on observational studies and a cognitive analysis of medication management workflows, conducted by medical practitioners. The physical design and product development of the template reflects best practices in Interaction Design, Visual Communication Design and Industrial Design. The design was incrementally refined using a series of iterative prototypes that were evaluated with expert practitioners in simulation studies and in the work setting. The final design of the template was implemented and monitored in a long-term study. Four years of data since the introduction of the AMT document significant improvements in medication handling safety and the AMT has been adapted for use at other medical centers across the United States..