Narrow Results Clear All
- Commentary 29
- Review 4
- Study 18
- Audiovisual 7
- Book/Report 12
- Legislation/Regulation 2
- Newspaper/Magazine Article 17
- Special or Theme Issue 6
- Toolkit 3
- Web Resource 8
- Award 2
- Meeting/Conference 6
- Press Release/Announcement 2
- Communication between Providers 14
- Culture of Safety
- Education and Training 22
- Error Reporting and Analysis 26
Human Factors Engineering
- Checklists 33
- Legal and Policy Approaches 9
- Logistical Approaches 8
- Quality Improvement Strategies 29
- Specialization of Care 2
- Teamwork 30
- Clinical Information Systems 3
- Device-related Complications 13
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Fatigue and Sleep Deprivation 1
- Identification Errors 3
- Interruptions and distractions 2
- Medical Complications 17
- Medication Errors/Preventable Adverse Drug Events 10
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 3
- Second victims 1
- Surgical Complications 18
- Internal Medicine 21
- Surgery 14
- Nursing 9
- Pharmacy 3
- Health Care Executives and Administrators 92
Health Care Providers
- Nurses 11
- Physicians 11
Non-Health Care Professionals
- Media 1
- Patients 5
Search results for "Human Factors Engineering"
Journal Article > Commentary
Bosk CL, Pedersen KZ. Lancet. 2019;393:978-979.
Safety sciences offer methods to enhance processes and develop organizational culture. This commentary elucidates on the limitations of applying the principles of a science of safety to health care. These weaknesses involve the tension between prospective and retrospective preventability, failure to consider human factors, and the need to understand how context affects care delivery.
Journal Article > Study
Kahwati LC, Sorensen AV, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019;45:231–240.
Labor and delivery is an inherently high-risk care setting. The Agency for Healthcare Research and Quality adapted its Comprehensive Unit-based Safety Program, a best practice toolkit incorporating teamwork, human factors engineering principles, and simulation training, for labor and delivery. In this pre–post evaluation study, staff reported improved safety culture and teamwork. Obstetric trauma and primary cesarean delivery rates declined after the intervention, but neonatal birth trauma rates increased. The authors note that incomplete implementation and lack of sustained program participation observed in the study should be addressed in order to improve obstetric and neonatal care safety. A recent Annual Perspective emphasizes the rising rate of severe maternal morbidity and summarizes national initiatives to improve safety in maternity care.
Journal Article > Review
Panagos PG, Pearlman SA. Clin Perinatol. 2017;44:645-662.
Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.
This report highlights how working conditions can affect health care workers and recommends seven strategies for organizations to improve workplace safety.
Dekker S. New York, NY: CRC Press; 2011. ISBN: 1439852251.
This book explores the complexity of patient safety improvement through the lens of human factors engineering and provides practical avenues for its application.
Weinstock M. Hosp Health Netw. 2011 Apr;85:46-49, 2.
This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one.
Spath PL, ed. San Francisco, CA: Jossey-Bass; 2011. ISBN: 9780470502402.
Error Reduction in Health Care remains one of the few comprehensive textbooks in patient safety. This updated edition covers key concepts in safety, beginning with the systems approach and the role of human factors engineering in patient safety. Also included are sections on measurement and interpretation of safety data, error analysis techniques, and approaches to improving patient safety (e.g., teamwork training and developing a culture of safety). The book's chapters are authored by experts in the field and strike a balance between background theory and practical approaches to reducing preventable adverse events.
Journal Article > Commentary
Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety.
Lewis GH, Vaithianathan R, Hockey PM, Hirst G, Bagian JP. Milbank Q. 2011;89:4-38.
This commentary describes aviation error prevention tactics and suggests that adopting these initiatives in health care can improve patient safety.
Sculli GL, Sine DM. Danvers, MA: HCPro, Inc; 2011. ISBN: 9781601467836.
This book describes how to apply aviation communication tactics to nursing practice.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. June 3, 2010;(45):1-3.
The Joint Commission issues sentinel event alerts to highlight areas of high risk and to promote rapid adoption of risk reduction strategies. This newly released alert focuses on violence in the health care setting, noting increasing rates of violent crimes such as assault, rape, and homicide, which are consistently among the top 10 types of sentinel events reported. Controlling access is viewed as a key protection strategy, and the alert also outlines techniques for identifying violent individuals and for training staff in violence management. The alert summarizes a series of suggested actions that will allow organizations to safeguard against these events. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.
The pace, diversity, and scope of an emergency department (ED) create a setting particularly prone to medical error. This comprehensive textbook provides important information on developing and advancing patient safety in emergency medicine, including relevant content on the ED setting, medical errors, organizational approaches to safety, teamwork, education, and human performance. The target audience is primarily emergency physicians and administrators but likely would extend to other allied health professionals and patient safety advocates. This textbook sets a foundation for the establishment of patient safety practices within emergency medicine.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.
No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS.
Rajasekaran K, Fairbanks RJ, Shah MN. EMS Mag. 2008 Sep;37:61-67.
This article describes how applying a just culture and systems approach to adverse events may help change the "blame-and-shame" mentality in emergency medical service provision.
Special or Theme Issue
Jt Comm J Qual Patient Saf. November 2007;33(suppl 1):3-84.
Tools/Toolkit > Toolkit
Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.
This manual provides nursing home staff with a step-by-step guide for medication management to reduce medication errors in long-term care.
Special or Theme Issue
Theor Issues Ergon Sci. 2007;8:365-507.
This special issue contains articles focusing on ergonomic research areas that intersect with patient safety, such as team management, work design, and safety culture.
Award > Award Recipient
Leape LL. Jt Comm J Qual Saf. 2004;30:653-658.
This interview with Dr. Leape, a 2004 Eisenberg Award winner, draws on his extensive experience as a leader in patient safety.
Award > Award Recipient
Uhlig PN, Brown J, Nason AK, Camelio A, Kendall E. Jt Comm J Qual Improv. 2002;28:666-672.
The Concord Hospital has been recognized for its effective use of teamwork and communication, and the Concord Collaborative Care Model draws from successful efforts in the aviation industry, human factors science, and high-reliability organizations.
Scheffler A, Zipperer LA, eds. Chicago, IL: National Patient Safety Foundation; 1999.
The proceedings from the 1998 Annenberg meeting hosted in Rancho Mirage, California.