Information Design Journal 17(2), 141–146

© 2009 John Benjamins Publishing Company

d o i : 10.1075/idj.17.2.09sch

Andreas Schneider
Medical nursing support pictograms
Ashikawa Red Cross Hospital, Hokkaido, Japan, 2008

Background
Confronted with an increasing number of accidential
misshandlings of patients by hospital staff – especially
a famous case of malpractice at Yokohama University
Hospital in 1999, the Ashikawa Red Cross Hospital
understood that it needed to take action.
As the principal causes of these accidents could be
traced to a lack of staff and the consequential overload of
work for those on duty, the hospital came to realize that
access to information on the patients’ specific conditions
and needs was both the problem and the key to a solution.
In order to determine how to respond to the particular Figure 1. Simple pictograms produced by staff and used
requirements of each patients’ requests – generally not in provisional testing. Testing in situ helped to reinforce or
clearly articulated – as well as to memorize the routine modify initial assumptions.
treatments for any individual, doctors and nurses had
to consult health records filed in complex documents; Initiators
visitors had to turn to one of the available staff. This took
time and attention and easily produced misunderstand- After Masahiro Shimazu, a member of the Japanese Sign
ings due to false interpretations of the highly specialized Design Association - SDA, had developed some of the
vocabulary or lack of attention to detail within the stress- initial Pictograms for the Japanese Society for Quality and
ful context of receiving multiple demands at once. Safety in Healthcare at “X Hospital” in Hokkaido, the Ashi-
Staff started to experiment with simple visuals direct- kawa Red Cross Hospital took the initiative to conduct a
ly attached to the patients’ beds as a means to provide more in-depth study and realization of the project.
immediate cues on ‘Dos’ and ‘Don’ts’ and other optional A special development group was established,
characterizations of the patients’ condition. Seeing the comprised by representatives of the hospital, the
positive effect of these ad-hoc aides, the hospital decided construction company responsible for the hospital’s
to seek the professional help of designers. facilities, designers and also a maker of hospital beds.

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Process
The Ashikawa Red Cross Hospital had already prepared
a list of specific information and functionality it wanted
to have visualized using pictograms when collaboration
with the Japanese Sign Design Association began.
Initial ideas were evaluated and further specified in
several meetings with the personnel most concerned:
doctors and nurses. The SDA then followed a process they
had already successfully pursued when developing the
series of ISO 7001 pictograms for public services in 2002:
different members presented their proposals to an evalua-
tion committee specifically formed for the purpose, which
then nominated a lead designer to follow through with
the production of the complete set of images.
The first series of designs underwent thorough test-
ing based on methods defined in the ISO 9186 standard,
involving not only the professional staff, but also patients
and non-professionals representing external visitors,
such as patients‘ relatives.
Issues under scrutiny were those concerned not only
with the immediate comprehension of the visuals, but
also matters dealing with emotional impact and the posi-
tioning of the pictogram sets at the patient‘s bed.
One critical factor for example has been the uneasiness
of patients to have their condition – and hence illness
Figure 3. Explaining the expected advantages of pictograms
– displayed so evidently for everyone to see. Rooms in
to the patient, while trying to understand the psychological
the hospital are typically shared by four or even more implications.
patients in a rather limited space. Gaining the patient‘s
understanding for the benefits of the pictograms and
soliciting identification became a major challenge.

Figure 2. Examples of preliminary designs, commissioned to an external design office.

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Result
The pictograms are organized into six groups:

歩行
Mobility 杖 歩行器 車いす 移 動

Figure 4.1. Walk. Figure 4.2. Cane. Figure 4.3. Walker. Figure 4.4. Wheelchair.

Position
ベッド 移 動 ヘッドアップ 制 限 3 0 度

英文：Frutiger_Black
ヘッドアップ 制 限 4 5 度

英文：Frutiger_Black
ヘッドアップ 制 限 6 0 度

英文：Frutiger_Black

Figure 5.1. Bed-rest. Figure 5.2. Head- Figure 5.3. Head- Figure 5.4. Head-
elevation limit 30°. elevation limit 45°. elevation limit 60°.

Toilet Activities
ベッド 上 排 泄 ポ ー タブ ル ト イレ

Figure 6.1. Bed-rest. Figure 6.2. Portable toilet.

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 Andreas Schneider • Medical nursing support pictograms idj 17(2), 2009, 141-146

Diet
飲 食 禁 止 ( 従 来 のもの ） 飲食禁止 食事禁止（朝）

和文：新ゴBold
食事禁止（昼）

和文：新ゴBold
食事禁止（夜）

和文：新ゴBold

Figure 7.1. Withhold Figure 7.2. Withhold Figure 7.3. Withhold Figure 7.4. Withhold Figure 7.5. Withhold
food and fluids 1. food and fluids 2. food and fluids breakfast. food and fluids lunch. food and fluids
evening.

Consumption of fluids
飲み物制限 飲み物計量中 服薬時水分可

Figure 8.1. Limited Figure 8.2. Monitoring Figure 8.3. Fluids for
fluids. fluids. drugs only.

Staff
左上肢処置禁止

英文：Frutiger Next_Heavy Cn
右上肢処置禁止

英文：Frutiger Next_Heavy Cn
リハ ビ リ 中 定時採血 尿管理

Figure 9.1. Don’t use Figure 9.2. Don’t use Figure 9.3. Undergoing Figure 9.4. Scheduled Figure 9.5. Monitor
the left arm. the right arm. rehabilitation. blood drawing. voiding.

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Andreas Schneider • Medical nursing support pictograms idj 17(2), 2009, 141-146

Figure 10. Pictograms are freely displayed in combinations on top

of the patient‘s bed, together with additional information, such
as timely notifications for certain precautions, and the names of
related personnel – nurse, doctor, and patient.

歩行 車いす 移 動 尿管理 ベ ッド 移 動 左上肢処置禁止 飲食禁止 リハ ビリ中 ポ ー タブ ルト イレ 飲み物計量中 食事禁止（昼） 食事禁止（朝） 服薬時水分可 杖 食事禁止（夜） 右上肢処置禁止 歩行器 ヘ ッドアップ 制 限 3 0 度 ヘ ッドアップ 制 限 6 0 度 ヘ ッドアップ 制 限 4 5 度 ベ ッド 上 排 泄 定時採血 飲み物制限

英文：Frutiger Next_Heavy Cn 和文：新ゴBold 和文：新ゴBold 和文：新ゴBold 英文：Frutiger Next_Heavy Cn 英文：Frutiger_Black 英文：Frutiger_Black 英文：Frutiger_Black

Figure 11. Initial statistical studies show rather significant differences in the statistical distribution of the usage of certain
pictograms. As a result, the grouping of information, prioritization and also the elimination or inclusion of pictograms may be
considered.

Doing the right thing at the right time requires a high further reduce opportunities for face-to-face commu-
level of expertise, experience and attention. Providing nication with the patient, gains in efficiency could not
visuals to support instant comprehension of situational justify application.
exigencies will most probably help to avoid misun-
derstandings, misinterpretations or simple negligence. Next Steps
However, considering the critical nature of patients‘
conditions, every attempt at simplification for the sake Continuing analysis of the pictograms‘ effectiveness and
of efficiency needs to be very carefully examined. If, by their acceptance should provide hints for improvements
some chance, the proposed type of Nursing Support of both the visual rendition of information and function,
Pictograms should result in a false sense of security or as well as the underlying structure.

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Andreas Schneider • Medical nursing support pictograms
As the feedback gained from the current application
in the Ashikawa Red Cross Hospital has been clearly
encouraging, the Sign Design Association is actively
promoting installations in hospitals all over Japan.
While a lack of resources limits the current scope to the
national level, this project certainly deserves to be taken
on in other countries as well, aiming at inclusion in one
of the relevant ISO standards. Such expansion however
requires redesigning some of the pictograms whose
imagery would not work in different cultural contexts.
Also, integration of these pictograms with applications
in related domains, such as user interfaces of electronic
health records – EHR – or manuals for medication and
hospital staff training, will require a concerted effort by
many additional parties.
Other demands are to further enhance visibility of
the pictograms in adverse conditions, such as darkened
rooms, and also to continue research on how more
detailed advisories could be integrated in an equally clear
fashion. The use of auditive information, for example,
might augment the field of applications by addressing yet
another sensory channel.
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idj 17(2), 2009, 141-146
References
Japanese Sign Design Association - SDA
Takeuchi Matoko
takeuchi@takeuchidesign.co.jp
SDA committee
Shimazu Kazuhiro, Shimazu Environmental Graphics, Toyama
Takeuchi Makoto, Takeuchi Design, Tokyo
Miyazawa Isao, GK Design, Tokyo
Miyazaki Katsura, KMD, Tokyo
Watanabe Taro, Emotional Space Design, Tokyo
Pictogram Design
Nakagawa Keizo, Nihon Design Center Graphic, Yokohama
Development Committee
Yokoi Kuniko, Toho University, Medical Department, Tokyo
Hashimoto Mime, Shuto University, Health and Elderly De-
partment, Tokyo
Hamano Takuya. Kajima Kensetsu, Tokyo
Shimazu Kazuhiro, Shimazu Environmental Graphics, Toyama
Fujihara Yasuhito, Paramount Bed, Tokyo
Fujita Mamoru, Yamashita Architects, Tokyo
ISO 7001:2007
Graphical symbols -- Public information symbols
ISO 22727:2007
Graphical symbols -- Creation and design of public informa-
tion symbols -- Requirements
ISO 9186-1:2007
Graphical symbols -- Test methods -- Part 1: Methods for test-
ing comprehensibility
ISO 9186-2:2008
Graphical symbols -- Test methods -- Part 2: Method for test-
ing perceptual quality
About the author
Andreas Schneider has been teaching at the
Institute for Advanced Sciences Arts and Media
– IAMAS, in Gifu prefecture, Japan since 2001
and is visiting lecturer at WASEDA university
in Tokyo, and the National Iinstitute for Design
– NID, in Ahmedabad, India. He is one of the
founding members of the Institute for Information Design
Japan – IIDj, and board member of the International Institute for
Information Design – IIID, in Vienna.