AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (68)

•Diagnostic Errors (17)

•Identification Errors (27)

•Discontinuities, Gaps, and Hand-Off Problems (28)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (258)

•Medical Complications (36)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (80)

•Transfusion Complications (3)

•Psychological and Social Complications (9)

Origin/Sponsor

•Africa (1)

•Asia (12)

•Australia and New Zealand (24)

•Central and South America (2)

Resource Types

•Journal Article (344)

•Legislation/Regulation (9)

•Meeting/Conference (4)

•Newspaper/Magazine Article (72)

•Press Release/Announcement (9)

•Special or Theme Issue (15)

•Tools/Toolkit (3)

•Web Resource (3)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (78)

•Active Errors (191)

•Latent Errors (63)

•Near Miss (14)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (16)

•Medical Device Design (47)

•Medical Alarm Design (9)

•Checklists (57)

•Failure Mode Effects Analysis (5)

Clinical Areas

•Allied Health Services (3)

•Medicine (296)

•Nursing (93)

•Pharmacy (122)

Target Audience

•Health Care Providers (357)

•Health Care Executives and Administrators (414)

•Non-Health Care Professionals (166)

•Patients (20)

Setting of Care

•Hospitals (311)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (33)

•Outpatient Surgery (4)

•Patient Transport (4)

1 - 20 of 480

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STUDY

Association of interruptions with an increased risk and severity of medication administration errors.

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

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

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.

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.

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

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

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

STUDY

High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process.

Hartel MJ, Staub LP, Röder C, Eggli S. BMC Health Serv Res. 2011;11:199.

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.

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

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

Niazkhani Z, Pirnejad H, van der Sijs H, Aarts J. Int J Med Inform. 2011;80:490-506.

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.

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

The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference.

Sanborn M, Gabay M, Moody ML. Hosp Pharm. 2009;44:159-164.

STUDY

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

Marquard JL, Henneman PL, He Z, Jo J, Fisher DL, Henneman EA. J Exp Psychol Appl. 2011;17:247-256.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

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.

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.

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