Challenges and opportunities for improving patient safety through human factors and systems engineering.

Pascale Carayon; Abigail Wooldridge; Bat-Zion Hose; Megan Salwei; James Benneyan

Commentary

Emerging Classic

Challenges and opportunities for improving patient safety through human factors and systems engineering.

December 5, 2018

Carayon P, Wooldridge A, Hose B-Z, et al. Health Aff (Millwood). 2018;37(11):1862-1869.

View more articles from the same authors.

System and process weaknesses can hinder safe patient care. This commentary raises awareness of human factors engineering as a key opportunity for enhancing patient safety. The authors provide recommendations to drive adoption and spread of human factors strategies through targeted education, clinician–engineer partnerships, and coordinated improvement efforts.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients.

March 11, 2020

Work system barriers and facilitators of a team health information technology.

September 13, 2023

Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.

June 22, 2022

Information flow during pediatric trauma care transitions: things falling through the cracks.

September 11, 2019

Care transition of trauma patients: processes with articulation work before and after handoff.

February 16, 2022

SEIPS 3.0: human-centered design of the patient journey for patient safety.

February 19, 2020

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation.

May 11, 2022

From tasks to processes: the case for changing health information technology to improve health care.

April 1, 2009

Human factors in patient safety as an innovation.

June 2, 2010

Human factors of complex sociotechnical systems.

June 28, 2006

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

January 8, 2020

A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety.

March 25, 2015

Contributions of tele-intensive care unit (tele-ICU) technology to quality of care and patient safety.

January 23, 2013

A roadmap to advance patient safety in ambulatory care.

January 20, 2021

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Exploring performance obstacles of intensive care nurses.

November 19, 2008

A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units.

October 12, 2005

The effects of computerized provider order entry implementation on communication in intensive care units.

February 20, 2013

Human factors and ergonomics as a patient safety practice.

July 31, 2013

Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life.

April 1, 2009

Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units.

November 28, 2012

State of science: human factors and ergonomics in healthcare.

September 4, 2013

FMEA team performance in health care: a qualitative analysis of team member perceptions.

June 24, 2009

Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences.

November 14, 2007

EHR safety: the way forward to safe and effective systems.

April 2, 2008

Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

August 17, 2011

February 8, 2017

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

June 13, 2012

Strategies for improving family engagement during family-centered rounds.

May 29, 2013

ICU nurses' acceptance of electronic health records.

July 13, 2011

Understanding patient and clinician reported nonroutine events in ambulatory surgery.

March 22, 2023

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.

November 6, 2013

Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital.

April 17, 2019

The use of a checklist in a pediatric oncology clinic.

October 2, 2013

Human factors systems approach to healthcare quality and patient safety.

August 14, 2013

Evaluation of nurse interaction with bar code medication administration technology in the work environment.

March 28, 2007

Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.

March 15, 2017

Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework.

May 29, 2019

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients.

October 3, 2013

Hospital ratings: a guide for the perplexed.

June 3, 2015

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.

May 31, 2017

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

July 13, 2022

Are parents who feel the need to watch over their children's care better patient safety partners?

December 6, 2017

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

August 23, 2006

Parent perceptions of children's hospital safety climate.

April 17, 2013

Family-initiated dialogue about medications during family-centered rounds.

February 11, 2015

Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data.

July 11, 2018

Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework.

September 5, 2018

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

July 21, 2021

An approach to assessing patient safety in hospitals in low-income countries.

June 3, 2015

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

January 25, 2023

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Understanding context specificity: the effect of contextual factors on clinical reasoning.

September 2, 2020

Low rate of completion of recommended tests and referrals in an academic primary care practice with resident trainees.

January 31, 2024

Completion of recommended tests and referrals in telehealth vs in-person visits.

December 6, 2023

A lethal hidden curriculum—death of a medical student from opioid use disorder.

September 4, 2019

Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.

June 13, 2018

Systems engineering analysis of diagnostic referral closed-loop processes.

March 9, 2022

Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.

January 20, 2021

Your company's secret change agents.

May 25, 2005

Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center

January 15, 2020

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

November 29, 2023

User-centered collaborative design and development of an inpatient safety dashboard.

September 20, 2017

Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.

January 17, 2024

Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery.

November 26, 2014

Health professionals' perspectives of safety issues in mental health services: a qualitative study.

March 31, 2021

A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services.

August 5, 2020

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

December 7, 2016

How should clinicians minimize bias when responding to suspicions about child abuse?

February 22, 2023

Engaging patients as safety partners: some considerations for ensuring a culturally and linguistically appropriate approach.

November 12, 2008

Culture, language, and patient safety: making the link.

September 27, 2006

Clinical risk management and patient safety education for nurses: a critique.

July 26, 2006

Processes for disciplining nurses for unprofessional conduct of a serious nature: a critique.

May 4, 2005

Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial.

December 2, 2020

Incorporating quality and safety values into a CLABSI simulation experience.

September 28, 2016

How to reduce stigma and bias in clinical communication: a narrative review.

October 12, 2022

Observing sources of system resilience using in situ alarm simulations.

October 25, 2023

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

January 26, 2011

Recognising and responding to 'cutting corners' when providing nursing care: a qualitative study.

October 12, 2016

Electronic health record alert–related workload as a predictor of burnout in primary care providers.

August 30, 2017

Comparison of health care worker satisfaction before vs after implementation of a communication and optimal resolution program in acute care hospitals.

April 5, 2023

Focus on the Quadruple Aim: development of a resiliency center to promote faculty and staff wellness initiatives.

June 6, 2018

Detecting and assessing suicide ideation during the COVID-19 pandemic.

May 26, 2021

A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs.

August 6, 2008

The meaning of justice in safety incident reporting.

November 7, 2007

Does the Leapfrog program help identify high-quality hospitals?

August 6, 2008

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.

December 17, 2014

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals.

September 30, 2009

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach.

December 2, 2020

Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID-19.

July 5, 2023

For children admitted to hospital, what interventions improve medication safety on ward rounds?

March 1, 2023

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.

June 22, 2022

Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system.

May 21, 2008

Medication safety in older adults: home-based practice patterns.

June 22, 2005

Making the transition to nursing bedside shift reports.

May 30, 2012

Chemotherapy medication errors.

April 11, 2018

Pediatric obesity and safety in inpatient settings: a systematic literature review.

May 21, 2014

Medication regimen complexity and hospital readmission for an adverse drug event.

January 15, 2014

Related Resources

Interview

In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety

November 27, 2023

Perspectives on Safety

The Role of Undergraduate Nursing Education in Patient Safety

November 27, 2023

Perspectives on Safety

Beyond the Pandemic: Creating Total Systems Safety

August 30, 2023

Perspectives on Safety

Interview

In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety

August 30, 2023

Towards safe conversational agents in healthcare.

June 14, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Home medical device safety tops ECRI'S list of healthcare technology.

February 15, 2023

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Inequity and Iatrogenic Harm.

August 31, 2022

The Uneven Burden of Maternal Mortality in the U.S.

August 10, 2022

Mitigating racial bias in machine learning.

June 22, 2022

Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors: Guidance for Industry.

May 25, 2022

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Structural racism and the COVID-19 experience in the United States.

July 7, 2021

Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS.

April 21, 2021

Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles.

March 24, 2021

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

February 10, 2021

To err Is human, unless you are a healthcare provider.

August 3, 2020

An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic.

July 1, 2020

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice.

June 19, 2019

Addressing Problematic Opioid Use in OECD Countries.

June 5, 2019

Is it time for safeguards in the adoption of robotic surgery?

May 15, 2019

Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.

May 8, 2019

When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?

April 17, 2019

Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.

February 27, 2019

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Engineers

Latent Errors

Legal and Policy Approaches

Challenges and opportunities for improving patient safety through human factors and systems engineering.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Challenges and opportunities for improving patient safety through human factors and systems engineering.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site