AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (57)

•Diagnostic Errors (12)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (25)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (203)

•Medical Complications (39)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (47)

•Transfusion Complications (2)

•Psychological and Social Complications (7)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (7)

Resource Types

•Journal Article (268)

•Legislation/Regulation (9)

•Meeting/Conference (10)

•Newspaper/Magazine Article (89)

•Press Release/Announcement (1)

•Special or Theme Issue (18)

•Tools/Toolkit (3)

•Web Resource (7)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (56)

•Active Errors (97)

•Latent Errors (49)

•Near Miss (8)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (8)

•Medical Device Design (35)

•Medical Alarm Design (14)

•Checklists (12)

•Failure Mode Effects Analysis (1)

Clinical Areas

•Medicine (240)

•Nursing (50)

•Pharmacy (100)

Target Audience

•Health Care Providers (265)

•Health Care Executives and Administrators (344)

•Non-Health Care Professionals (238)

•Patients (29)

Setting of Care

•Hospitals (233)

•Residential Facilities (2)

•Ambulatory Care (37)

•Outpatient Surgery (2)

•Patient Transport (2)

1 - 20 of 447

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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.

SPECIAL OR THEME ISSUE

Biomedical Complexity and Error.

Patel VL, Kahol K, Buchman T, eds. J Biomed Inform. 2011;44:385-506.

COMMENTARY

Enhancing electronic health record usability in pediatric patient care: a scenario-based approach.

Patterson ES, Zhang J, Abbott P, et al. Jt Comm J Qual Patient Saf. 2013;39:129-135.

STUDY

Description of inpatient medication management using cognitive work analysis.

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

COMMENTARY

Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.

Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.

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.

STUDY

The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance.

Ahmed A, Chandra S, Herasevich V, Gajic O, Pickering BW. Crit Care Med. 2011;39:1626-1634.

STUDY

Handling anticipated exceptions in clinical care: investigating clinician use of 'exit strategies' in an electronic health records system.

Zheng K, Hanauer DA, Padman R, et al. J Am Med Inform Assoc. 2011;18:883-889.

NEWSPAPER/MAGAZINE ARTICLE

Safety in numbers? Try connectivity.

Dyell D. Patient Saf Qual Healthc. January/February 2012;9:34-37.

NEWSPAPER/MAGAZINE ARTICLE

Catching deadly drug mistakes.

Landro L. Wall Street Journal. January 18, 2010;D5.

STUDY

Predictive combinations of monitor alarms preceding in-hospital code blue events.

Hu X, Sapo M, Nenov V, et al. J Biomed Inform. 2012;45:913-921.

STUDY

Improving the usability of intravenous medication labels to support safe medication delivery.

Bauer DT, Guerlain S. Int J Ind Ergon. 2011;41:394-399.

COMMENTARY classic

Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety.

Lewis GH, Vaithianathan R, Hockey PM, Hirst G, Bagian JP. Milbank Q. 2011;89:4-38.

STUDY

Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.

Armbruster DA, Alexander DB. Clin Chim Acta. 2006;373:37-43.

ORGANIZATIONAL POLICY/GUIDELINES

Guidelines for Design and Construction of Health Care Facilities.

Washington, DC: The American Institute of Architects; 2006.

BOOK/REPORT

Health Care Comes Home: The Human Factors.

Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.

NEWSPAPER/MAGAZINE ARTICLE

For all the right reasons.

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

STUDY

The nature and occurrence of registration errors in the emergency department.

Hakimzada AF, Green RA, Sayan OR, Zhang J, Patel VL. Int J Med Inform. 2008;77:169-175.

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.

COMMENTARY

Detection of patient risk by nurses: a theoretical framework.

Despins LA, Scott-Cawiezell J, Rouder JN. J Adv Nurs. 2010;66:465-474.

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