AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (49)

•Diagnostic Errors (11)

•Identification Errors (22)

•Discontinuities, Gaps, and Hand-Off Problems (28)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (182)

•Medical Complications (29)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (64)

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•Psychological and Social Complications (11)

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•Africa (1)

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Resource Types

•Journal Article (295)

•Legislation/Regulation (7)

•Meeting/Conference (5)

•Newspaper/Magazine Article (46)

•Press Release/Announcement (5)

•Special or Theme Issue (14)

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Error Types

•Epidemiology of Errors and Adverse Events (64)

•Active Errors (116)

•Latent Errors (50)

•Near Miss (8)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (4)

•Medical Device Design (29)

•Medical Alarm Design (4)

•Checklists (38)

•Failure Mode Effects Analysis (3)

Clinical Areas

•Allied Health Services (2)

•Medicine (242)

•Nursing (85)

•Pharmacy (68)

Target Audience

•Health Care Providers (280)

•Health Care Executives and Administrators (371)

•Non-Health Care Professionals (174)

•Patients (8)

Setting of Care

•Hospitals (253)

•Psychiatric Facilities (1)

•Residential Facilities (6)

•Ambulatory Care (18)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 397

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STUDY

Identifying the 'right patient': nurse and consumer perspectives on verifying patient identity during medication administration.

Kelly T, Roper C, Elsom S, Gaskin C. Int J Ment Health Nurs. 2011;20:371-379.

STUDY

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.

STUDY

Association of interruptions with an increased risk and severity of medication administration errors.

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.

SPECIAL OR THEME ISSUE

CMS 30-minute rule for drug administration needs revision.

ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.

STUDY

Paediatric nurses' understanding of the process and procedure of double-checking medications.

Dickinson A, McCall E, Twomey B, James N. J Clin Nurs. 2010;19:728-735.

STUDY

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

Holden RJ, Scanlon MC, Patel NR, et al. BMJ Qual Saf. 2011;20:15-24.

STUDY

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

Marquard JL, Henneman PL, He Z, Jo J, Fisher DL, Henneman EA. J Exp Psychol Appl. 2011;17:247-256.

STUDY

The application of Aronson's taxonomy to medication errors in nursing.

Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.

REVIEW

Work interruptions and their contribution to medication administration errors: an evidence review.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.

STUDY

Medication Administration Time Study (MATS): nursing staff performance of medication administration.

Elganzouri ES, Standish CA, Androwich I. J Nurs Adm. 2009;39:204-210.

STUDY

Nurses' clinical reasoning: processes and practices of medication safety.

Dickson GL, Flynn L. Qual Health Res. 2012;22:3-16.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

STUDY

Incorrect surgical counts: a qualitative analysis.

Rowlands A, Steeves R. AORN J. 2010;92:410-419.

COMMENTARY

Increasing patient safety and surgical team communication by using a count/time out board.

Edel EM. AORN J. 2010;92:420-424.

STUDY

Strategies used by critical care nurses to identify, interrupt, and correct medical errors.

Henneman EA, Gawlinski A, Blank FS, Henneman PL, Jordan D, McKenzie JB. Am J Crit Care. 2010;19:500-509.

COMMENTARY

Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.

Nunnally ME, Bitan Y. J Patient Saf. 2006;2:124-131.

STUDY

No interruptions please: impact of a no interruption zone on medication safety in intensive care units.

Anthony K, Wiencek C, Bauer C, Daly B, Anthony MK. Crit Care Nurse. 2010;30:21-29.

STUDY

The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study.

Schimmel AM, Becker ML, van den Bout T, Taxis K, van den Bemt PM. Int J Nurs Stud. 2011;48:791-797.

STUDY

Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field.

Brown-Brumfield D, DeLeon A. AORN J. 2010;91:610-617.

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