AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (92)

•Diagnostic Errors (26)

•Identification Errors (35)

•Discontinuities, Gaps, and Hand-Off Problems (37)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (209)

•Medical Complications (80)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (157)

•Transfusion Complications (5)

•Psychological and Social Complications (8)

Origin/Sponsor

•Africa (1)

•Asia (8)

•Australia and New Zealand (19)

•Central and South America (2)

Resource Types

•Journal Article (342)

•Legislation/Regulation (14)

•Meeting/Conference (9)

•Newspaper/Magazine Article (74)

•Press Release/Announcement (11)

•Special or Theme Issue (23)

•Tools/Toolkit (4)

•Web Resource (11)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (97)

•Active Errors (201)

•Latent Errors (69)

•Near Miss (15)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (18)

•Medical Device Design (76)

•Medical Alarm Design (16)

•Checklists (111)

•Failure Mode Effects Analysis (2)

Clinical Areas

•Allied Health Services (3)

•Medicine (399)

•Nursing (50)

•Pharmacy (83)

Target Audience

•Health Care Providers (468)

•Health Care Executives and Administrators (413)

•Non-Health Care Professionals (175)

•Patients (36)

Setting of Care

•Hospitals (361)

•Psychiatric Facilities (1)

•Residential Facilities (6)

•Ambulatory Care (37)

•Outpatient Surgery (8)

•Patient Transport (7)

1 - 20 of 524

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COMMENTARY

Shortage of perioperative drugs: implications for anesthesia practice and patient safety.

De Oliveira GS Jr, Theilken LS, McCarthy RJ. Anesth Analg. 2011;113:1429-1435.

COMMENTARY

Vial Mistakes Involving Heparin.

Vanderveen T. AHRQ WebM&M [serial online]. May 2009.

SPECIAL OR THEME ISSUE

Safety in Anaesthesia.

Staender S, ed. Best Pract Res Clin Anaesthesiol. 2011;25:109-304.

REVIEW

Medication errors—new approaches to prevention.

Merry AF, Anderson BJ. Paediatr Anaesth. 2011;21:743-753.

NEWSPAPER/MAGAZINE ARTICLE

Beyond the count: preventing the retention of foreign objects.

PA-PSRS Patient Saf Advis. June 2009;6:39-45.

COMMENTARY

The contribution of labelling to safe medication administration in anaesthetic practice.

Merry AF, Shipp DH, Lowinger JS. Best Pract Res Clin Anaesthesiol. 2011;25:145-159.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.

REVIEW

Failed spinal anaesthesia: mechanisms, management, and prevention.

Fettes PD, Jansson JR, Wildsmith JA. Br J Anaesth. 2009;102:739-748.

STUDY

Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-1323.

STUDY

Preprinted order sets as a safety intervention in pediatric sedation.

Broussard M, Bass PF 3rd, Arnold CL, McLarty JW, Bocchini JA Jr. J Pediatr. 2009;154:865-868.

NEWSPAPER/MAGAZINE ARTICLE

Program encourages reporting accidents waiting to happen: the Good Catch Awards.

McCook A. Anesthesiology News. Sept 2011;37:9.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

COMMENTARY

Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution.

Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H. Ann Emerg Med. 2010;55:341-344.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

STUDY

Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.

Cima RR, Kollengode A, Clark J, et al. Jt Comm J Qual Patient Saf. 2011;37:51-58.

STUDY

Incorrect surgical counts: a qualitative analysis.

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

NEWSPAPER/MAGAZINE ARTICLE

Nearly 90 major medical mistakes logged at Utah hospitals in 2008.

May H. Salt Lake Tribune. June 26, 2009.

STUDY

Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: what would Semmelweis think?

Biddle C, Shah J. Am J Infect Control. 2012;40:756-759.

COMMENTARY

Dangerous Shift

Patterson ES. AHRQ WebM&M [serial online]. November 2008.

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