AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (74)

•Diagnostic Errors (20)

•Identification Errors (35)

•Discontinuities, Gaps, and Hand-Off Problems (48)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (258)

•Medical Complications (90)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (91)

•Transfusion Complications (6)

•Psychological and Social Complications (9)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (15)

Resource Types

•Journal Article (398)

•Legislation/Regulation (13)

•Meeting/Conference (10)

•Newspaper/Magazine Article (115)

•Press Release/Announcement (6)

•Special or Theme Issue (26)

•Tools/Toolkit (5)

•Web Resource (12)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (85)

•Active Errors (147)

•Latent Errors (82)

•Near Miss (14)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (18)

•Medical Device Design (51)

•Medical Alarm Design (29)

•Checklists (97)

•Failure Mode Effects Analysis (6)

Clinical Areas

•Allied Health Services (1)

•Medicine (410)

•Nursing (78)

•Pharmacy (124)

Target Audience

•Health Care Providers (425)

•Health Care Executives and Administrators (502)

•Non-Health Care Professionals (255)

•Patients (49)

Setting of Care

•Hospitals (429)

•Residential Facilities (6)

•Ambulatory Care (48)

•Outpatient Surgery (6)

•Patient Transport (5)

1 - 20 of 643

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BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

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

BOOK/REPORT classic

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.

NEWSPAPER/MAGAZINE ARTICLE

Driving out errors, with mom in mind.

Weinstock M. Hosp Health Netw. April 2011.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing violence in the health care setting.

Sentinel Event Alert. June 3, 2010;(45):1-3.

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.

NEWSPAPER/MAGAZINE ARTICLE

"Plug and Play" hospitals: medical devices that exchange data could make hospitals safer.

Grifantini K. Technol Rev. July 9, 2008.

COMMENTARY

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Jt Comm J Qual Patient Saf. 2010;36:519-524.

NEWSPAPER/MAGAZINE ARTICLE

Safety in numbers? Try connectivity.

Dyell D. Patient Saf Qual Healthc. January/February 2012;9:34-37.

NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.

REVIEW

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.

Semple SJ, Roughead EE. Aust New Zealand Health Policy. 2009;6:24.

STUDY

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

NEWSPAPER/MAGAZINE ARTICLE

For all the right reasons.

Hagland M. Healthc Informatics. 2009;26:40-44.

TOOLKIT

Wristband Standardization Initiative.

Austin, TX: Texas Hospital Association; October 2008.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

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.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

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.

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

Using Lean to improve medication administration safety: in search of the "perfect dose."

Ching JM, Long C, Williams BL, Blackmore CC. Jt Comm J Qual Patient Saf. 2013;39:195-204.

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