AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (70)

•Diagnostic Errors (13)

•Identification Errors (37)

•Discontinuities, Gaps, and Hand-Off Problems (39)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (242)

•Medical Complications (77)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (70)

•Transfusion Complications (7)

•Psychological and Social Complications (9)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (12)

Resource Types

•Journal Article (314)

•Legislation/Regulation (11)

•Meeting/Conference (10)

•Newspaper/Magazine Article (123)

•Press Release/Announcement (6)

•Special or Theme Issue (23)

•Tools/Toolkit (8)

•Web Resource (11)

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Error Types

•Epidemiology of Errors and Adverse Events (67)

•Active Errors (130)

•Latent Errors (72)

•Near Miss (11)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (10)

•Medical Device Design (42)

•Medical Alarm Design (21)

•Checklists (68)

•Failure Mode Effects Analysis (6)

Clinical Areas

•Medicine (350)

•Nursing (68)

•Pharmacy (125)

Target Audience

•Health Care Providers (358)

•Health Care Executives and Administrators (407)

•Non-Health Care Professionals (214)

•Patients (70)

Setting of Care

•Hospitals (376)

•Residential Facilities (5)

•Ambulatory Care (46)

•Outpatient Surgery (5)

•Patient Transport (3)

1 - 20 of 560

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AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

NEWSPAPER/MAGAZINE ARTICLE

Hospital bracelets face hurdles as they fix hazard.

Hartocollis A. New York Times. September 25, 2008; Metropolitan Desk section: A1.

NEWSPAPER/MAGAZINE ARTICLE

Disruptive behavior affects hospital financial health.

Crane M. Medscape Medical News. December 11, 2010.

AUDIOVISUAL PRESENTATION

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.

COMMENTARY

Developing process-support tools for patient safety: finding the balance between validity and feasibility.

Marsteller JA, Holzmueller CG, Makary M, et al. Jt Comm J Qual Patient Saf. 2008;34:604-607.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

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

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

REVIEW

Fall prevention in hospitals: an integrative review.

Spoelstra SL, Given BA, Given CW. Clin Nurs Res. 2012;21:92-112.

NEWSPAPER/MAGAZINE ARTICLE

Officials investigate infants' heparin OD at Texas hospital.

Vonfremd M, Ibanga I. ABC News.com. July 10, 2008.

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.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Reduction in pediatric identification band errors: a quality collaborative.

Phillips SC, Saysana M, Worley S, Hain PD. Pediatrics. 2012;129:e1587-e1593.

NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

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

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

2009 National Patient Safety Goals.

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

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

Fixing America's hospitals.

Newsweek. October 16, 2006:44-68, 72.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing violence in the health care setting.

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

ORGANIZATIONAL POLICY/GUIDELINES

Standardising wristbands improves patient safety.

Safe Practice Notice 24. London, England: National Patient Safety Agency; July 3, 2007.

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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