AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (113)

•Diagnostic Errors (32)

•Identification Errors (46)

•Discontinuities, Gaps, and Hand-Off Problems (60)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (318)

•Medical Complications (107)

•Nonsurgical Procedural Complications (26)

•Surgical Complications (157)

•Transfusion Complications (7)

•Psychological and Social Complications (12)

Origin/Sponsor

•Africa (2)

•Asia (11)

•Australia and New Zealand (28)

•Central and South America (2)

Resource Types

•Journal Article (530)

•Legislation/Regulation (18)

•Meeting/Conference (12)

•Newspaper/Magazine Article (130)

•Press Release/Announcement (12)

•Special or Theme Issue (29)

•Tools/Toolkit (6)

•Web Resource (13)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (135)

•Active Errors (197)

•Latent Errors (91)

•Near Miss (17)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (22)

•Medical Device Design (73)

•Medical Alarm Design (33)

•Checklists (176)

•Failure Mode Effects Analysis (7)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (572)

•Health Care Executives and Administrators (641)

•Non-Health Care Professionals (316)

•Patients (54)

Setting of Care

•Hospitals (534)

•Psychiatric Facilities (2)

•Residential Facilities (6)

•Ambulatory Care (58)

•Outpatient Surgery (11)

•Patient Transport (5)

1 - 20 of 812

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STUDY

Practically speaking: rethinking hand hygiene improvement programs in health care settings.

Son C, Chuck T, Childers T, et al. Am J Infect Control. 2011;39:716-724.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

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.

STUDY

Patient safety begins with proper planning: a quantitative method to improve hospital design.

Birnbach DJ, Nevo I, Scheinman SR, Fitzpatrick M, Shekhter I, Lombard JL. Qual Saf Health Care. 2010;19:462-465.

COMMENTARY

'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.

Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. J Hosp Infect. 2007;67:9-21.

NEWSPAPER/MAGAZINE ARTICLE

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

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

SPECIAL OR THEME ISSUE

Infection Control in the Intensive Care Unit.

Crit Care Med. 2010;38:S265-S404.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

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

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Nursing and physician attire as possible source of nosocomial infections.

Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Am J Infect Control. 2011;39:555-559.

COMMENTARY

2009 National Patient Safety Goals.

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

STUDY

Medication safety initiative in reducing medication errors.

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

COMMENTARY

Emerging infections: the contact precautions controversy.

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

NEWSPAPER/MAGAZINE ARTICLE

Shakespeare was on target—don't be a borrower or lender.

ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.

STUDY

Preventing patient harms through systems of care.

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

COMMENTARY

Infection preventionist checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Cosgrove SE, Ristaino P, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:571-575.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

TOOLKIT

Wristband Standardization Initiative.

Austin, TX: Texas Hospital Association; October 2008.

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