Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.

This article reviews the theory behind the Swiss Cheese Model and how organizational influences, supervisory factors, preconditions for unsafe acts, and unsafe acts threaten patient safety.

The Root Cause Analysis and Action (RCA2) framework supports the implementation of sustainable systems-based improvements after investigation of patient safety events. The authors provide an overview of the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a decision tool called FACES and describe how these tools can be integrated into the RCA2 framework to foster a comprehensive, human factors analysis of patient safety events and the identification of broader system interventions.

… … This article discusses the action hierarchy, which is a tool for generating corrective actions to improve safety … factors and more on systems change . The authors propose a multifaceted definition of ‘systems change’ and a rubric … ‘systems change’ (‘systems change hierarchy’). … Wood LJ, Wiegmann DA. Beyond the Corrective Action Hierarchy: a …

… Am J Surg … Using a human factors engineering framework, this study reviewed video of residents performing a simulated hernia repair to identify and characterize errors … and commission errors (69%; defined as failure to perform a surgical step correctly). Nearly half of all errors went …

… whether integrating human factors engineering into a clinical decision support system can improve the diagnosis … clinical decision support for diagnostic decision-making: a scenario-based simulation study [published online ahead of …

Teamwork training can improve communication and prevention of adverse events in the operating room. In this study, focus groups with clinicians and operating room staff found that team members perceived the concept of the "team" and their roles in ensuring optimal handoff communication differently. This exploratory work has implications for the design of effective teamwork training programs.

… in checklist interventions. This commentary describes a model that uses a sociotechnical approach to guide implementation of …

… of patients from the ED to other hospital areas is a relatively understudied area of patient safety. …

… … World J Surg … This study reports on development of a "surgical flow disruption tool" for quantifying and …

This study demonstrated that a specialty-specific preoperative briefing tool decreased surgical flow disruptions and improved patient safety.

Using a trained observer to monitor for errors and flow disruptions in cardiac surgery operations, this study found that teamwork and communication failures were the strongest predictor of adverse outcomes.

The authors adapted an incident analysis model used in aviation to understand the human factors that contribute to errors in the operating room.