AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (80)

•Diagnostic Errors (21)

•Identification Errors (39)

•Discontinuities, Gaps, and Hand-Off Problems (45)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (268)

•Medical Complications (79)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (124)

•Transfusion Complications (7)

•Psychological and Social Complications (13)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (18)

•Central and South America (1)

Resource Types

•Journal Article (435)

•Legislation/Regulation (14)

•Meeting/Conference (12)

•Newspaper/Magazine Article (110)

•Press Release/Announcement (8)

•Special or Theme Issue (29)

•Tools/Toolkit (5)

•Web Resource (10)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (91)

•Active Errors (164)

•Latent Errors (72)

•Near Miss (13)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (17)

•Medical Device Design (42)

•Medical Alarm Design (17)

•Checklists (121)

•Failure Mode Effects Analysis (5)

Clinical Areas

•Allied Health Services (3)

•Medicine (412)

•Nursing (102)

•Pharmacy (122)

Target Audience

•Health Care Providers (451)

•Health Care Executives and Administrators (565)

•Non-Health Care Professionals (272)

•Patients (37)

Setting of Care

•Hospitals (408)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (44)

•Outpatient Surgery (7)

•Patient Transport (4)

1 - 20 of 671

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REVIEW

Fall prevention in hospitals: an integrative review.

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

MEETING/CONFERENCE PROCEEDINGS

Safety in the NICU: preventing medical errors.

Stokowski LA. Highlights of the National Association of Neonatal Nurses 22nd Annual Conference [Medscape.com]. March 8, 2007.

STUDY

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

Holden RJ, Scanlon MC, Patel NR, et al. BMJ Qual Saf. 2011;20:15-24.

STUDY

Strategies used by critical care nurses to identify, interrupt, and correct medical errors.

Henneman EA, Gawlinski A, Blank FS, Henneman PL, Jordan D, McKenzie JB. Am J Crit Care. 2010;19:500-509.

TOOLKIT

A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.

Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.

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.

SPECIAL OR THEME ISSUE

Risk, Safety and Reliability Special Issue.

Newbold D, Attree M, eds. J Nurs Manag. 2009;17:145-266.

COMMENTARY

Interruptions and medication errors: part I.

Flanders S, Clark AP. Clin Nurse Spec. 2010;24:281-285.

STUDY

Supporting structures for team situation awareness and decision making: insights from four delivery suites.

Mackintosh N, Berridge EJ, Freeth D. J Eval Clin Pract. 2009;15:46-54.

COMMENTARY

Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.

Nunnally ME, Bitan Y. J Patient Saf. 2006;2:124-131.

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.

REVIEW

Patient safety: Part II. Opportunities for improvement in patient safety.

Elston DM, Stratman E, Johnson-Jahangir H, et al. J Am Acad Dermatol. 2009;61:193-205.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

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

COMMENTARY

Medication room madness: calming the chaos.

Conrad C, Fields W, McNamara T, Cone M. J Nurs Care Qual. 2009;25:137-144.

SPECIAL OR THEME ISSUE

Patient Safety and Quality.

Lyndon A, Simpson KR, Bakewell-Sachs S, eds. J Perinat Neonat Nurs. 2010;24:1-89.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

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.

COMMENTARY

Medication errors: don't let them happen to you.

Anderson P, Townsend T. Amer Nurs Today. March 2010;5:23-27.

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.

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.

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