AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (111)

•Diagnostic Errors (32)

•Identification Errors (47)

•Discontinuities, Gaps, and Hand-Off Problems (63)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (329)

•Medical Complications (103)

•Nonsurgical Procedural Complications (27)

•Surgical Complications (153)

•Transfusion Complications (7)

•Psychological and Social Complications (12)

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•Africa (2)

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•Australia and New Zealand (29)

•Central and South America (2)

Resource Types

•Journal Article (536)

•Legislation/Regulation (18)

•Meeting/Conference (13)

•Newspaper/Magazine Article (127)

•Press Release/Announcement (10)

•Special or Theme Issue (30)

•Tools/Toolkit (6)

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Error Types

•Epidemiology of Errors and Adverse Events (135)

•Active Errors (201)

•Latent Errors (92)

•Near Miss (17)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (24)

•Medical Device Design (76)

•Medical Alarm Design (36)

•Checklists (170)

•Failure Mode Effects Analysis (7)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (579)

•Health Care Executives and Administrators (650)

•Non-Health Care Professionals (324)

•Patients (50)

Setting of Care

•Hospitals (528)

•Psychiatric Facilities (2)

•Residential Facilities (7)

•Ambulatory Care (61)

•Outpatient Surgery (11)

•Patient Transport (5)

1 - 20 of 816

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NEWSPAPER/MAGAZINE ARTICLE

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

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

COMMENTARY

ISMP medication error report analysis.

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

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.

COMMENTARY

Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child.

Wilson BL. J Spec Pediatr Nurs. 2010;15:84-87.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

STUDY

Impact of a standard medication chart on prescribing errors: a before-and-after audit.

Coombes ID, Stowasser DA, Reid C, Mitchell CA. Qual Saf Health Care. 2009;18:478-485.

AUDIOVISUAL PRESENTATION

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.

STUDY

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

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.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Preventing patient harms through systems of care.

Pronovost PJ, Bo-Linn GW. JAMA. 2012;308:769-770.

NEWSPAPER/MAGAZINE ARTICLE

For all the right reasons.

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

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

NEWSPAPER/MAGAZINE ARTICLE

Officials investigate infants' heparin OD at Texas hospital.

Vonfremd M, Ibanga I. ABC News.com. July 10, 2008.

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.

NEWSPAPER/MAGAZINE ARTICLE

Reducing alarm hazards: selection and implementation of alarm notification systems.

Gee T, Moorman BA. Patient Saf Qual Healthc. March/April 2011;8:14-17.

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