AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (76)

•Diagnostic Errors (15)

•Identification Errors (39)

•Discontinuities, Gaps, and Hand-Off Problems (40)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (265)

•Medical Complications (74)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (70)

•Transfusion Complications (7)

•Psychological and Social Complications (7)

Origin/Sponsor

•Africa (1)

•Asia (7)

•Australia and New Zealand (13)

•Central and South America (2)

Resource Types

•Journal Article (331)

•Legislation/Regulation (11)

•Meeting/Conference (6)

•Newspaper/Magazine Article (125)

•Press Release/Announcement (7)

•Special or Theme Issue (21)

•Tools/Toolkit (8)

•Web Resource (9)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (79)

•Active Errors (145)

•Latent Errors (73)

•Near Miss (13)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (10)

•Medical Device Design (51)

•Medical Alarm Design (24)

•Checklists (68)

•Failure Mode Effects Analysis (6)

Clinical Areas

•Medicine (367)

•Nursing (73)

•Pharmacy (137)

Target Audience

•Health Care Providers (376)

•Health Care Executives and Administrators (417)

•Non-Health Care Professionals (216)

•Patients (70)

Setting of Care

•Hospitals (391)

•Residential Facilities (5)

•Ambulatory Care (47)

•Outpatient Surgery (4)

•Patient Transport (3)

1 - 20 of 574

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NEWSPAPER/MAGAZINE ARTICLE

Hospital drug errors far from uncommon.

Lin R-G II, Watanabe T. Los Angeles Times. November 22, 2007;A1.

NEWSPAPER/MAGAZINE ARTICLE

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

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

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

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

For all the right reasons.

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

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

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

Impact of a standard medication chart on prescribing errors: a before-and-after audit.

Coombes ID, Stowasser DA, Reid C, Mitchell CA. Qual Saf Health Care. 2009;18:478-485.

AUDIOVISUAL PRESENTATION

When things go wrong.

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

NEWSPAPER/MAGAZINE ARTICLE

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

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

STUDY

A multiple-drawer medication layout problem in automated dispensing cabinets.

Pazour JA, Meller RD. Health Care Manag Sci. 2012;15:339-354.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Pressing for better quality across healthcare.

Levey NN. Los Angeles Times. October 4, 2011.

STUDY

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

NEWSPAPER/MAGAZINE ARTICLE

Heparin overdose in three infants revisits hospital error issues.

Phend C. MedPage Today. November 26, 2007.

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

Safe practice environment chapter proposed by USP.

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

ORGANIZATIONAL POLICY/GUIDELINES

Standardising wristbands improves patient safety.

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

COMMENTARY

2009 National Patient Safety Goals.

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

COMMENTARY

ISMP medication error report analysis.

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

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