Narrow Results Clear All
- Patient Safety Primers 5
- WebM&M Cases 101
Perspectives on Safety
- Interview 18
- Perspective 15
- Commentary 347
- Review 150
- Study 577
- Audiovisual 39
- Book/Report 71
- Legislation/Regulation 33
- Newspaper/Magazine Article 214
- Newsletter/Journal 2
- Special or Theme Issue 48
- Toolkit 13
- Web Resource 84
- Award 3
- Clinical Guideline 2
- Grant 2
- Meeting/Conference 20
- Press Release/Announcement 29
Communication between Providers
- Sbar 5
- Communication between Providers 218
- Culture of Safety 150
Education and Training
- Simulators 50
- Students 13
Error Reporting and Analysis
- Error Analysis 117
- Error Reporting 88
Human Factors Engineering
- Checklists 472
Legal and Policy Approaches
- Regulation 25
- Logistical Approaches 84
- Policies and Operations 3
Quality Improvement Strategies
- Reminders 18
- Research Directions 4
- Specialization of Care 47
- Teamwork 119
- Clinical Information Systems 137
- Transparency and Accountability 3
- Alert fatigue 26
- Device-related Complications 214
- Diagnostic Errors 79
- Discontinuities, Gaps, and Hand-Off Problems 120
- Drug shortages 3
- Failure to rescue 4
- Fatigue and Sleep Deprivation 10
- Identification Errors 66
- Inpatient suicide 3
- Interruptions and distractions 65
- Medical Complications 164
- Medication Errors/Preventable Adverse Drug Events 399
- MRI safety 4
- Nonsurgical Procedural Complications 44
- Overtreatment 1
- Psychological and Social Complications 62
- Second victims 1
- Surgical Complications 354
- Transfusion Complications 8
- Home Care 16
- Operating Room 318
- General Hospitals 556
- Long-Term Care 17
- Outpatient Surgery 19
- Patient Transport 7
- Psychiatric Facilities 4
- Allied Health Services 5
- Dentistry 4
- Anesthesiology 105
- Critical Care 119
- Gynecology 31
- Cardiology 25
- Geriatrics 22
- Hematology 10
- Obstetrics 29
- Pediatrics 110
- Primary Care 30
- Radiology 41
- Nursing 180
- Palliative Care 1
- Pharmacy 197
- Family Members and Caregivers 9
Health Care Executives and Administrators
- Nurse Managers 157
- Risk Managers 151
Health Care Providers
- Nurses 213
- Pharmacists 78
- Physicians 217
Non-Health Care Professionals
- Educators 73
- Engineers 233
- Media 3
- Patients 99
- Africa 5
- China 7
- Australia and New Zealand 65
- Central and South America 3
- United Kingdom 186
- Canada 72
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 73
- United States Federal Government 96
Search results for "Human Factors Engineering"
- Human Factors Engineering
Meeting/Conference > California Meeting/Conference
Behavioral Health—Strategic Facility Design Innovations That Improve Treatment Outcomes, Safety and the Bottom Line Workshop.
The Center for Health Design. May 15, 2019, Hyatt Regency Los Angeles Airport, Los Angeles, CA.
Meeting/Conference > Maryland Meeting/Conference
Armstrong Institute for Patient Safety and Quality. March 25–29, 2019; Armstrong Institute for Patient Safety and Quality, Baltimore, MD.
This course will cover various patient safety topics, including key concepts and human factors engineering strategies. The program will also explore the comprehensive unit-based safety program model of safety improvement. Participants will be engaged in problem-solving and developing patient safety initiatives.
Meeting/Conference > United States Meeting/Conference
Washington Patient Safety Coalition. WPSC Lunchtime Webinar Series. March 20, 2019; 2:00 PM (Eastern).
Insights from patients and families can help inform error prevention and patient safety. This segment of a four-part webinar series on diagnostic improvement will explore the use of a diagnostic process framework to identify weaknesses that contribute to patient harm and how patient and family engagement can help address those breakdowns. Sue Sheridan is the featured speaker.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Journal Article > Commentary
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
Henriksen K, Rodrick D, Grace EN, Shofer M, Brady PJ. J Patient Saf. 2019 Feb 9; [Epub ahead of print].
Applying systems engineering strategies from problem analysis through postimplementation evaluation can lead to solutions grounded in actual practice and learning for individuals, teams, and organizations. This commentary discusses the Agency for Healthcare Research and Quality patient safety learning laboratories initiative. The authors, who serve as program officers and oversee the grants, review lessons learned through experiences of grantees.
Perspectives on Safety > Perspective
Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
with commentary by Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc, Teaching Patient Safety, February 2019
This piece spotlights the need for educational and cultural transformation to achieve sustainable progress in patient outcomes and health.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
Journal Article > Commentary
The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.
Durstenfeld MS, Statman S, Dikman A, et al. Am J Med Qual. 2019 Jan 18; [Epub ahead of print].
Academic medical centers are working to increase resident engagement in patient safety work. Building on Reason's system failure investigation model, this commentary describes the integration of monthly educational opportunities into actual improvement efforts. Core elements of the program rely on effective case selection, root cause analysis, and resident-led discussion.
Journal Article > Commentary
Xiao Y, Abebe E, Gurses AP. J Patient Saf Risk Manag. 2019;24:30–36.
Journal Article > Study
Kahwati LC, Sorensen AV, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019 Jan 10; [Epub ahead of print].
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.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019.
Burnout can diminish the safety of clinicians, students, health care workers, and patients. This report suggests institutions apply design thinking and systems thinking methods to develop interventions to reduce burnout and stress. A past Annual Perspective covered the impact of burnout on patient safety.
Patient Safety Primers
Human factors engineering is the discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.
Journal Article > Study
George D, Hassali MA, Hss AS. JMIR Hum Factors. 2018;5:e12232.
This mixed-methods study examined the usability of a mobile application for reporting medication errors at a referral hospital in Malaysia. Usability improved over each of the three cycles of testing and iterative redesign, but physician and nurse testers expressed concern about whether the safety culture supported reporting.
Web Resource > Multi-use Website
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academy of Medicine.
Burnout can impair health care workers' ability to practice safely. This project will examine the evidence on the conditions that contribute to clinician burnout as well as the consequences of burnout on clinicians and patients. The committee will also assess system-level approaches to reduce burnout and improve clinician well-being and define gaps in the research base that must be addressed to support evidence-based interventions.
Journal Article > Review
Elmontsri M, Banarsee R, Majeed A. JRSM Open. 2018;9:2054270418786112.
Health care safety is a global concern. This review examined the literature on improvement experience from developed countries and identified common themes. The authors recommend a patient-centered, systems-oriented approach built on leadership, teamwork, transparency, and communication as key elements for effectively implementing improvement efforts in developing countries.
Special or Theme Issue
Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.
Special or Theme Issue
Health Aff (Milwood). 2018;37:1723-1908.
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Journal Article > Study
LaDonna KA, Ginsburg S, Watling C. Acad Med. 2018;93:1713-1718.
Although individual clinician performance issues leading to patient harm tend to cluster in a small group of physicians, virtually all physicians commit errors of some kind in their career. Researchers interviewed 28 academic physicians about how they cope with errors. Clinicians reported a balance between accepting personal responsibility and identifying systems-level factors that enhanced patient risk of harm.