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 (30)

•Identification Errors (43)

•Discontinuities, Gaps, and Hand-Off Problems (49)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (287)

•Medical Complications (86)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (154)

•Transfusion Complications (6)

•Psychological and Social Complications (9)

Origin/Sponsor

•Africa (1)

•Asia (9)

•Australia and New Zealand (25)

•Central and South America (1)

Resource Types

•Journal Article (491)

•Legislation/Regulation (16)

•Meeting/Conference (12)

•Newspaper/Magazine Article (113)

•Press Release/Announcement (9)

•Special or Theme Issue (28)

•Tools/Toolkit (5)

•Web Resource (13)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (116)

•Active Errors (186)

•Latent Errors (78)

•Near Miss (16)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (23)

•Medical Device Design (49)

•Medical Alarm Design (22)

•Checklists (156)

•Failure Mode Effects Analysis (4)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (548)

•Health Care Executives and Administrators (597)

•Non-Health Care Professionals (295)

•Patients (43)

Setting of Care

•Hospitals (458)

•Psychiatric Facilities (2)

•Residential Facilities (7)

•Ambulatory Care (55)

•Outpatient Surgery (10)

•Patient Transport (6)

1 - 20 of 739

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COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

COMMENTARY

Medication reconciliation in the emergency department: opportunities for workflow redesign.

Hummel J, Evans PC, Lee H. Qual Saf Health Care. 2010;19:531-535.

STUDY

Medication errors among acutely ill and injured children treated in rural emergency departments.

Marcin JP, Dharmar M, Cho M, et al. Ann Emerg Med. 2007;50:361-367.e1-2.

STUDY

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.

SPECIAL OR THEME ISSUE

Medical errors and safety systems.

Pearlman MD, ed. Clin Obstet Gynecol. 2010;53:471-585.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

Comparison of Broselow tape measurements versus physician estimations of pediatric weights.

Rosenberg M, Greenberger S, Rawal A, Latimer-Pierson J, Thundiyil J. Am J Emerg Med. 2011;29:482-488.

COMMENTARY

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

Eisen LA, Savel RH. Chest. 2009;136:910-917.

COMMENTARY

Weighing in on medication safety.

Paparella S. J Emerg Nurs. 2009;35:553-555.

STUDY

Color coded medication safety system reduces community pediatric emergency nursing medication errors.

Feleke R, Kalynych CJ, Lundblom B, Wears R, Luten R, Kling D. J Patient Saf. 2009;5:79-85.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

COMMENTARY

Patient safety strategies: are we on the same team?

Moffatt-Bruce SD, Funai EF, Nash M, Gabbe SG. Obstet Gynecol. 2012;120:743-745.

STUDY

The nature and occurrence of registration errors in the emergency department.

Hakimzada AF, Green RA, Sayan OR, Zhang J, Patel VL. Int J Med Inform. 2008;77:169-175.

STUDY

Can aviation-based team training elicit sustainable behavioral change?

Sax HC, Browne P, Mayewski RJ, et al. Arch Surg. 2009;144:1133-1137.

BOOK/REPORT classic

Patient Safety in Emergency Medicine.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.

NEWSPAPER/MAGAZINE ARTICLE

Preventing medication errors during codes.

ISMP Medication Safety Alert! Acute Care Edition. February 9, 2011;16:1-3.

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.

STUDY

Medication safety initiative in reducing medication errors.

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

COMMENTARY

X-ray Flip.

Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

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