AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (124)

•Diagnostic Errors (32)

•Identification Errors (45)

•Discontinuities, Gaps, and Hand-Off Problems (59)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (342)

•Medical Complications (103)

•Nonsurgical Procedural Complications (29)

•Surgical Complications (163)

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•Psychological and Social Complications (10)

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Resource Types

•Journal Article (551)

•Legislation/Regulation (19)

•Meeting/Conference (13)

•Newspaper/Magazine Article (142)

•Press Release/Announcement (14)

•Special or Theme Issue (30)

•Tools/Toolkit (8)

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Error Types

•Epidemiology of Errors and Adverse Events (139)

•Active Errors (217)

•Latent Errors (97)

•Near Miss (16)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (28)

•Medical Device Design (89)

•Medical Alarm Design (37)

•Checklists (183)

•Failure Mode Effects Analysis (9)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (597)

•Health Care Executives and Administrators (665)

•Non-Health Care Professionals (328)

•Patients (63)

Setting of Care

•Hospitals (543)

•Psychiatric Facilities (2)

•Residential Facilities (7)

•Ambulatory Care (63)

•Outpatient Surgery (13)

•Patient Transport (5)

1 - 20 of 852

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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.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

COMMENTARY

ISMP medication error report analysis.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

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

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.

COMMENTARY

ISMP medication error report analysis.

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

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.

COMMENTARY

Emerging infections: the contact precautions controversy.

Zastrow RL. Am J Nurs. 2011;111:47-53.

STUDY

Medication safety initiative in reducing medication errors.

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

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

Analysis and prioritization of near-miss adverse events in a radiology department.

Thornton RH, Miransky J, Killen AR, Solomon SB, Brody LA. AJR Am J Roentgenol. 2011;196:1120-1124.

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

In Conversation with...Dean Schillinger, MD

AHRQ WebM&M [serial online]. February/March 2009.

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