AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (84)

•Diagnostic Errors (21)

•Identification Errors (43)

•Discontinuities, Gaps, and Hand-Off Problems (41)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (311)

•Medical Complications (71)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (99)

•Transfusion Complications (5)

•Psychological and Social Complications (7)

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•Asia (6)

•Australia and New Zealand (19)

•Central and South America (1)

Resource Types

•Journal Article (400)

•Legislation/Regulation (12)

•Meeting/Conference (11)

•Newspaper/Magazine Article (122)

•Press Release/Announcement (11)

•Special or Theme Issue (23)

•Tools/Toolkit (5)

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•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (128)

•Active Errors (195)

•Latent Errors (99)

•Near Miss (15)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (18)

•Medical Device Design (62)

•Medical Alarm Design (23)

•Checklists (86)

•Failure Mode Effects Analysis (7)

Clinical Areas

•Allied Health Services (3)

•Medicine (403)

•Nursing (82)

•Pharmacy (150)

Target Audience

•Health Care Providers (448)

•Health Care Executives and Administrators (518)

•Non-Health Care Professionals (247)

•Patients (52)

Setting of Care

•Hospitals (395)

•Psychiatric Facilities (1)

•Residential Facilities (10)

•Ambulatory Care (55)

•Outpatient Surgery (8)

•Patient Transport (7)

1 - 20 of 652

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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.

Cohen MR. Hosp Pharm. 2008;43:618-621.

NEWSPAPER/MAGAZINE ARTICLE

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

STUDY

Improving the usability of intravenous medication labels to support safe medication delivery.

Bauer DT, Guerlain S. Int J Ind Ergon. 2011;41:394-399.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:12-13, 36.

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

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

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

NEWSPAPER/MAGAZINE ARTICLE

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Heed this warning! Don't miss important computer alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 8, 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.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

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

STUDY

Communication errors in dispatch of air medical transport.

Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.

NEWSPAPER/MAGAZINE ARTICLE

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2008;43:168-171.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

COMMENTARY

Medication tracers: a systems approach to medication safety.

Hendrick EC, Montanya KR, Griffith N. Hosp Pharm. 2007;42:916-920.

NEWSPAPER/MAGAZINE ARTICLE

A long way to go.

DerGurahian J. Mod Healthc. December 7, 2009.

STUDY

Designing decision support for insulin ordering in a computerized provider order entry system.

Wright L, Feldott CC, Hargrove FR. Hosp Pharm. 2007;42:158–161.

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