AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (126)

•Diagnostic Errors (31)

•Identification Errors (52)

•Discontinuities, Gaps, and Hand-Off Problems (57)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (317)

•Medical Complications (107)

•Nonsurgical Procedural Complications (26)

•Surgical Complications (166)

•Transfusion Complications (9)

•Psychological and Social Complications (13)

Origin/Sponsor

•Africa (1)

•Asia (12)

•Australia and New Zealand (23)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (521)

•Legislation/Regulation (16)

•Meeting/Conference (11)

•Newspaper/Magazine Article (141)

•Press Release/Announcement (13)

•Special or Theme Issue (27)

•Tools/Toolkit (12)

•Web Resource (15)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (111)

•Active Errors (221)

•Latent Errors (112)

•Near Miss (20)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (28)

•Medical Device Design (91)

•Medical Alarm Design (32)

•Checklists (176)

•Failure Mode Effects Analysis (6)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (569)

•Health Care Executives and Administrators (616)

•Non-Health Care Professionals (312)

•Patients (75)

Setting of Care

•Hospitals (537)

•Residential Facilities (11)

•Ambulatory Care (59)

•Outpatient Surgery (12)

•Patient Transport (6)

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NEWSPAPER/MAGAZINE ARTICLE

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

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

NEWSPAPER/MAGAZINE ARTICLE

Pressing for better quality across healthcare.

Levey NN. Los Angeles Times. October 4, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

SPECIAL OR THEME ISSUE

The English Patient Safety Programme.

J Health Serv Research Pol. 2010;15(suppl 1):S1-S91.

NEWSPAPER/MAGAZINE ARTICLE

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

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

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.

AUDIOVISUAL PRESENTATION

When things go wrong.

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

NEWSPAPER/MAGAZINE ARTICLE

Radiation offers new cures, and ways to do harm.

Bogdanich W. New York Times. January 24, 2010:A1.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

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

'Alarm fatigue’ a factor in 2nd death.

Kowalczyk L. Boston Globe. September 21, 2011.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.

NEWSPAPER/MAGAZINE ARTICLE

A long way to go.

DerGurahian J. Mod Healthc. December 7, 2009.

COMMENTARY

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2009;110:459-479.

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.

STUDY

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

NEWSPAPER/MAGAZINE ARTICLE

Fixing America's hospitals.

Newsweek. October 16, 2006:44-68, 72.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

NEWSPAPER/MAGAZINE ARTICLE

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.

SPECIAL OR THEME ISSUE

Medical Malpractice and Errors.

Health Aff (Millwood). 2010;29:1564-1619.

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