Charting a new course

How colour-coded observation charts pioneered by UQ researchers are helping save more lives in hospitals.

A female nurse in blue scrubs looks down at a hospital chart examining information. Behind them, a male patient is resting in a hospital bed.

We’ve all seen movies or TV shows in which a doctor picks up a patient’s observation chart, gives it a quick once over and instantly orders a test or treatment. Observation charts have an air of mystique about them; full of symbols and information only medical professionals can decipher.

In reality, however, it turns out these charts are less Grey’s Anatomy and more grey area.

“Observation charts were generally designed by clinicians with no particular human factors or psychology training,” says Professor Mark Horswill from UQ’s School of Psychology.

He says that can lead to complications that could have been picked up earlier being missed.

“You get people being monitored on these charts, and then they deteriorate or have a negative outcome, and so the question was why were these clinical staff missing so many of these warning signs?”

This was a problem that Associate Professor Marcus Watson (UQ School of Medicine, UQ School of Psychology, and former Executive Director of the Clinical Skills Development Service in Queensland Health Metro North) recognised from his human factors work with the military.

In 2009, he set out to address it by recruiting Professor Horswill and another colleague from the School of Psychology, Dr Andrew Hill, to examine the design of these crucial charts that measure heart rate, blood pressure, temperature and more.

“Everything was a grid of numbers, and it’s very hard when you’re confronted with a table like that to easily spot when any of those numbers is outside the normal range, even for highly experienced people,” Professor Horswill says.

“Marcus realised, hang on – there’s a problem here clinicians are trying to solve that is actually a problem psychologists could have some valuable input into, and that’s when we set up our group.”

Professor Mark Horswill.

The team secured funding from the Australian Commission for Safety and Quality of Healthcare to investigate how observation charts could be made more user-friendly and life-saving.

It's an area Professor Horswill is well-qualified to work on, having previously used his knowledge of human behaviours to solve real-world problems and reduce harm. With a primary research focus on reducing road crash deaths, he led a team with Dr Hill that developed the hazard perception test that is now a compulsory part of Queensland’s driver licensing process. The introduction of the test was associated with a 13 per cent drop per year in novice driver crashes on Queensland roads.

Associate Professor Watson and the team proposed that the typical blocky, black-and-white chart design was adding to the ‘cognitive load’ for clinicians, meaning crucial details about a patient's safety were more likely to be overlooked.

Professor Mark Horswill. A man wearing a white collared shirt and black jacket. He has salt and pepper hair and is smiling.

Professor Mark Horswill.

Professor Mark Horswill.

An older-style hospital observation class. The colours are black and white, with the text small and blocky. It is full of columns for listing numbers, and is quite hard to read.

An example of a traditional hospital observation chart.

An example of a traditional hospital observation chart.

“Psychology and human factors are able to tell us how many things people can hold in their short term memory at any one time, how people’s attention is drawn to some things but not others, and how people prioritise and aggregate information,” he says.

“As you start exceeding what our very limited cognitive load can handle, then people start making all sorts of mistakes.”

Using this information, the multi-disciplinary team designed the Adult Deterioration Detection System (ADDS) chart to allow clinicians to plot data on a graph with coloured backgrounds.

For example, if a heart rate reading goes above a certain level, it will cross into a new coloured section, denoting what should happen next to help the patient.

“What you’re essentially doing is removing the need for the clinician to memorise the cut-offs for abnormal and normal readings, because they can literally see it right there on the page,” Professor Horswill says.

Professor Horswill says vital signs can also be scored individually, then added together.

“That gives you a number, which is essentially a summary of the physiological status of the patient, how sick they are overall, and you can use that number to decide whether to take action or not,” he explains.

“With our chart, clinicians can see much more clearly at a glance whether the person is in trouble or not, and they don’t need years and years of experience to do so.”

Associate Professor Watson says it’s a simple solution that allows doctors to work faster and smarter.

“The redesigned charts help them figure out what’s actually wrong with the patient, rather than filling their heads with the cut-offs they’re trying to memorise,” he says.

“There’s no high-tech here. By simply understanding how human behaviour works and how humans process information, you can have enormous impacts that can save people’s lives.”
The new hospital observation chart design, featuring clearer columns and reference sections, with an easier to read layout.

An example of Professor Horswill and his team's new colourful hospital observation chart design. Credit: Professor Mark Horswill, School of Psychology.

An example of Professor Horswill and his team's new colourful hospital observation chart design. Credit: Professor Mark Horswill, School of Psychology.

That’s certainly what the chart did during hospital trials. Nambour Hospital saw an 11 per cent decrease in overall mortality across the whole facility, while Waikato Hospital in New Zealand saw a 45 per cent reduction in cardiac arrests.

“We put our chart side-by-side with a range of other charts, all of which were produced by health professionals, and found that our chart had about a third of the number of errors as some of the other charts,” Professor Horswill says.

Versions of the ADDS chart, adapted for specific requirements, are now used in around 180 public hospitals and primary health care centres in Queensland, with some private hospitals also seeing their value.

The charts have also begun rolling out nationwide.

Professor Horswill says the ADDS chart project was a satisfying moment of collaboration that is having transformational impact.

“The most satisfying part of this project is how our academic work translated so fast into real world outcomes," he says.

"There are people potentially alive now, who would otherwise not be, thanks to changing the arrangement of information on a piece of paper."

Contact details

Professor Mark Horswill (L) and Associate Professor Marcus Watson (R)

Professor Mark Horswill, School of Psychology

Phone: +61 7 334 69520

Associate Professor Marcus Watson, School of Psychology


Professor Mark Horswill and Associate Professor Marcus Watson

Professor Mark Horswill (L) and Associate Professor Marcus Watson (R)

Professor Mark Horswill (L) and Associate Professor Marcus Watson (R)