AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (86)

•Diagnostic Errors (21)

•Identification Errors (38)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (267)

•Medical Complications (69)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (102)

•Transfusion Complications (8)

•Psychological and Social Complications (11)

Origin/Sponsor

•Africa (1)

•Asia (13)

•Australia and New Zealand (30)

•Central and South America (2)

Resource Types

•Journal Article (413)

•Legislation/Regulation (10)

•Meeting/Conference (4)

•Newspaper/Magazine Article (92)

•Press Release/Announcement (7)

•Special or Theme Issue (16)

•Tools/Toolkit (5)

•Web Resource (3)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (130)

•Active Errors (199)

•Latent Errors (83)

•Near Miss (14)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (20)

•Medical Device Design (57)

•Medical Alarm Design (21)

•Checklists (98)

•Failure Mode Effects Analysis (7)

Clinical Areas

•Allied Health Services (3)

•Medicine (410)

•Nursing (103)

•Pharmacy (107)

Target Audience

•Health Care Providers (406)

•Health Care Executives and Administrators (493)

•Non-Health Care Professionals (217)

•Patients (32)

Setting of Care

•Hospitals (411)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (34)

•Outpatient Surgery (6)

•Patient Transport (5)

1 - 20 of 587

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STUDY

Medication safety initiative in reducing medication errors.

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

STUDY

The application of Aronson's taxonomy to medication errors in nursing.

Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.

REVIEW

Work interruptions and their contribution to medication administration errors: an evidence review.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.

STUDY

Medication Administration Time Study (MATS): nursing staff performance of medication administration.

Elganzouri ES, Standish CA, Androwich I. J Nurs Adm. 2009;39:204-210.

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

No interruptions please: impact of a no interruption zone on medication safety in intensive care units.

Anthony K, Wiencek C, Bauer C, Daly B, Anthony MK. Crit Care Nurse. 2010;30:21-29.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

Medication room madness: calming the chaos.

Conrad C, Fields W, McNamara T, Cone M. J Nurs Care Qual. 2009;25:137-144.

STUDY

The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study.

Schimmel AM, Becker ML, van den Bout T, Taxis K, van den Bemt PM. Int J Nurs Stud. 2011;48:791-797.

STUDY

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.

STUDY

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

Holden RJ, Scanlon MC, Patel NR, et al. BMJ Qual Saf. 2011;20:15-24.

STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

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.

REVIEW

Fall prevention in hospitals: an integrative review.

Spoelstra SL, Given BA, Given CW. Clin Nurs Res. 2012;21:92-112.

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

Evaluation of contextual influences on the medication administration practice of paediatric nurses.

Davis L, Ware R, McCann D, Keogh S, Watson K. J Adv Nurs. 2009;65:1293-1299.

SPECIAL OR THEME ISSUE

Adverse events: expecting too much of nurses and too little of nursing research.

Jordan S, ed. J Nurs Manag. 2011;19:287-417.

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

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

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