AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (118)

•Diagnostic Errors (31)

•Identification Errors (46)

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

•Fatigue and Sleep Deprivation (5)

•Medication Safety (313)

•Medical Complications (103)

•Nonsurgical Procedural Complications (28)

•Surgical Complications (155)

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•Africa (1)

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Resource Types

•Journal Article (530)

•Legislation/Regulation (16)

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•Newspaper/Magazine Article (130)

•Press Release/Announcement (12)

•Special or Theme Issue (29)

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Error Types

•Epidemiology of Errors and Adverse Events (123)

•Active Errors (216)

•Latent Errors (92)

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Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (26)

•Medical Device Design (78)

•Medical Alarm Design (36)

•Checklists (173)

•Failure Mode Effects Analysis (4)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (577)

•Health Care Executives and Administrators (635)

•Non-Health Care Professionals (319)

•Patients (54)

Setting of Care

•Hospitals (505)

•Psychiatric Facilities (2)

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•Ambulatory Care (60)

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1 - 20 of 803

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STUDY

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-314.

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

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

SPECIAL OR THEME ISSUE

Patient safety and quality in the pediatric intensive care unit.

Pediatr Crit Care Med. 2007;8(suppl):S1-S43.

STUDY

The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance.

Ahmed A, Chandra S, Herasevich V, Gajic O, Pickering BW. Crit Care Med. 2011;39:1626-1634.

STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

STUDY

Variability in the concentrations of intravenous drug infusions prepared in a critical care unit.

Wheeler DW, Degnan BA, Sehmi JS, et al. Intensive Care Med. 2008;34:1441-1447.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

STUDY

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

STUDY

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety.

Halbesleben JRB, Savage GT, Wakefield DS, Wakefield BJ. Health Care Manage Rev. 2010;35:124-133.

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.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

STUDY

Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.

Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.

NEWSPAPER/MAGAZINE ARTICLE

Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

COMMENTARY

Preventing sentinel events caused by family members.

Wall Y, Kautz DD. Dimens Crit Care Nurs. 2011;30:25-27.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

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