AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (105)

•Diagnostic Errors (21)

•Identification Errors (36)

•Discontinuities, Gaps, and Hand-Off Problems (32)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (258)

•Medical Complications (77)

•Nonsurgical Procedural Complications (20)

•Surgical Complications (113)

•Transfusion Complications (4)

•Psychological and Social Complications (7)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (13)

•Central and South America (1)

Resource Types

•Journal Article (379)

•Legislation/Regulation (16)

•Meeting/Conference (12)

•Newspaper/Magazine Article (107)

•Press Release/Announcement (11)

•Special or Theme Issue (21)

•Tools/Toolkit (5)

•Web Resource (12)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (94)

•Active Errors (160)

•Latent Errors (68)

•Near Miss (13)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (16)

•Medical Device Design (55)

•Medical Alarm Design (22)

•Checklists (93)

•Failure Mode Effects Analysis (3)

Clinical Areas

•Allied Health Services (1)

•Medicine (404)

•Nursing (63)

•Pharmacy (125)

Target Audience

•Health Care Providers (466)

•Health Care Executives and Administrators (474)

•Non-Health Care Professionals (233)

•Patients (46)

Setting of Care

•Hospitals (374)

•Psychiatric Facilities (1)

•Residential Facilities (6)

•Ambulatory Care (50)

•Outpatient Surgery (9)

•Patient Transport (4)

1 - 20 of 614

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COMMENTARY

Addressing safety concerns about U-500 insulin in a hospital setting.

Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.

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.

SPECIAL OR THEME ISSUE

Patient safety and quality in the pediatric intensive care unit.

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

NEWSPAPER/MAGAZINE ARTICLE

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

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

PRESS RELEASE/ANNOUNCEMENT

Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2009.

AUDIOVISUAL PRESENTATION

Preventing Medical Errors.

Food and Drug Administration (FDA) Patient Safety News. Show #79. September 2008.

COMMENTARY

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2009;110:459-479.

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

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.

NEWSPAPER/MAGAZINE ARTICLE

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

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

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.

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

Program encourages reporting accidents waiting to happen: the Good Catch Awards.

McCook A. Anesthesiology News. Sept 2011;37:9.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

ISMP medication error report analysis.

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

COURSE MATERIAL/CURRICULUM

Situational Awareness and Patient Safety: A Learning Package.

Parush A, Campbell C, Hunter A, et al. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2011. ISBN: 9781926588100.

COMMENTARY

On the Other Hand

Henneman EA. AHRQ WebM&M [serial online]. May 2007.

COMMENTARY

Engineering risk analysis of a hospital oxygen supply system.

Deleris LA, Yeo GL, Seiver A, Pate-Cornell ME. Med Decis Making. 2006;26:162-172.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing adverse events caused by emergency electrical power system failures.

Sentinel Event Alert. September 6, 2006;(37):1-3.

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

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