… … Salwei ME, Hoonakker P, Carayon P, et al. Usability of a human factors-based clinical decision support in the …

… J Patient Saf … This article reviews the theory behind the … unsafe acts, and unsafe acts threaten patient safety. … Wiegmann DA, L JW, T NC, et al. Understanding the "Swiss … cheese model" and its application to patient safety. J Patient Saf. Epub 2021 Apr 15. …

… J Healthc Risk Manag … The Root Cause Analysis and Action … (HFACS), the Human Factors Intervention Matrix (HFIX), and a decision tool called FACES and describe how these tools can … and the identification of broader system interventions. … Wiegmann DA, Wood LJ, Solomon DB, et al. J Healthc Risk …

This article discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).

… 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 …

This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.

… The Journal of surgical research … J Surg Res … Higher acuity trauma patients were more likely … of patients from the ED to other hospital areas is a relatively understudied area of patient safety. …

… World journal of surgery … 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.

… Surgery … Surgery … Using a trained observer to monitor for errors and flow disruptions …

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