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 (23)

•Identification Errors (38)

•Discontinuities, Gaps, and Hand-Off Problems (44)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (295)

•Medical Complications (80)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (117)

•Transfusion Complications (6)

•Psychological and Social Complications (9)

Origin/Sponsor

•Africa (2)

•Asia (12)

•Australia and New Zealand (27)

•Central and South America (2)

Resource Types

•Journal Article (427)

•Legislation/Regulation (15)

•Meeting/Conference (12)

•Newspaper/Magazine Article (99)

•Press Release/Announcement (10)

•Special or Theme Issue (24)

•Tools/Toolkit (9)

•Web Resource (10)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (111)

•Active Errors (172)

•Latent Errors (75)

•Near Miss (14)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (17)

•Medical Device Design (47)

•Medical Alarm Design (20)

•Checklists (127)

•Failure Mode Effects Analysis (3)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (497)

•Health Care Executives and Administrators (540)

•Non-Health Care Professionals (249)

•Patients (44)

Setting of Care

•Hospitals (437)

•Psychiatric Facilities (2)

•Residential Facilities (6)

•Ambulatory Care (55)

•Outpatient Surgery (8)

•Patient Transport (5)

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COMMENTARY

In Conversation with...Dean Schillinger, MD

AHRQ WebM&M [serial online]. February/March 2009.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

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

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

STUDY

Applying root cause analysis to improve patient safety: decreasing falls in postpartum women.

Chen KH, Chen LR, Su S. Qual Saf Health Care. 2010;19:138-143.

NEWSPAPER/MAGAZINE ARTICLE

Safeguarding the storage of drug products.

PA-PSRS Patient Saf Advis. June 2010;7:46-51.

NEWSPAPER/MAGAZINE ARTICLE

Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?

ISMP Medication Safety Alert! Acute Care Edition. November 29, 2012;17:1-3.

STUDY

Improving prescription drug warnings to promote patient comprehension.

Wolf MS, Davis TC, Bass PF, et al. Arch Intern Med. 2010;170:50-56.

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

COMMENTARY

ISMP medication error report analysis.

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

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Neuromuscular blocking agents: reducing associated wrong-drug errors.

PA-PSRS Patient Saf Advis. December 2009;6:109-114.

REVIEW

Failed spinal anaesthesia: mechanisms, management, and prevention.

Fettes PD, Jansson JR, Wildsmith JA. Br J Anaesth. 2009;102:739-748.

STUDY

Nurses' clinical reasoning: processes and practices of medication safety.

Dickson GL, Flynn L. Qual Health Res. 2012;22:3-16.

STUDY

A patient safety curriculum for medical residents based on the perspectives of residents and supervisors.

Jansma JD, Wagner C, Bijnen AB. J Patient Saf. 2011;7:99-105.

PRESS RELEASE/ANNOUNCEMENT

Important change to heparin container labels to clearly state the total drug strength.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012.

COMMENTARY

ISMP medication error report analysis.

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

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