AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (69)

•Diagnostic Errors (25)

•Identification Errors (32)

•Discontinuities, Gaps, and Hand-Off Problems (48)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (249)

•Medical Complications (74)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (68)

•Transfusion Complications (6)

•Psychological and Social Complications (11)

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•Asia (8)

•Australia and New Zealand (27)

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Resource Types

•Journal Article (373)

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•Meeting/Conference (8)

•Newspaper/Magazine Article (86)

•Press Release/Announcement (7)

•Special or Theme Issue (21)

•Tools/Toolkit (5)

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Error Types

•Epidemiology of Errors and Adverse Events (89)

•Active Errors (140)

•Latent Errors (66)

•Near Miss (11)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (17)

•Medical Device Design (48)

•Medical Alarm Design (25)

•Checklists (70)

•Failure Mode Effects Analysis (2)

Clinical Areas

•Allied Health Services (1)

•Medicine (360)

•Nursing (65)

•Pharmacy (104)

Target Audience

•Health Care Providers (359)

•Health Care Executives and Administrators (471)

•Non-Health Care Professionals (275)

•Patients (31)

Setting of Care

•Hospitals (381)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (45)

•Outpatient Surgery (3)

•Patient Transport (3)

1 - 20 of 566

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STUDY

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

Niazkhani Z, Pirnejad H, van der Sijs H, Aarts J. Int J Med Inform. 2011;80:490-506.

STUDY

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.

Holden RJ. Cogn Tech Work. 2011;13:11-29.

BOOK/REPORT

Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.

OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.

NEWSPAPER/MAGAZINE ARTICLE

For all the right reasons.

Hagland M. Healthc Informatics. 2009;26:40-44.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.

REVIEW

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.

Semple SJ, Roughead EE. Aust New Zealand Health Policy. 2009;6:24.

STUDY

Description of inpatient medication management using cognitive work analysis.

Pingenot AA, Shanteau J, Sengstacke DN. Comput Inform Nurs. 2009;27:379-392.

STUDY

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

Hundt AS, Adams JA, Schmid JA, et al. Int J Med Inform. 2013;82:25-38.

NEWSPAPER/MAGAZINE ARTICLE

Shakespeare was on target—don't be a borrower or lender.

ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.

REVIEW

A systematic review of the psychological literature on interruption and its patient safety implications.

Li SY, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.

STUDY

Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts.

Baysari MT, Reckmann MH, Li L, Day RO, Westbrook JI. J Am Med Inform Assoc. 2012;19:1003-1010.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

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.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

STUDY

PCA safety data review after clinical decision support and smart pump technology implementation.

Prewitt J, Schneider S, Horvath M, Hammond J, Jackson J, Ginsberg B. J Patient Saf. 2013;9:103-109.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors associated with documented allergies.

PA-PSRS Patient Saf Advis. September 2008;5:75-80.

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