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Search results for "Human Factors Engineering"

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Journal Article > Study

An acetaminophen icon helps reduce medication decision errors in an experimental setting.

Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.

Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.

Journal Article > Commentary

An innovative approach to the surgical time out: a patient-focused model.

Kozusko SD, Elkwood L, Gaynor D, Chagares SA. AORN J. 2016;103:617-622.

The surgical time out has been advocated globally as a strategy to improve team communication and reduce errors. This commentary discusses the development of a checklist for use before, during, and after surgery that engages patients and families in the process. The authors review the results of the program since its inception in 2011 which includes no incidents of wrong-site surgeries.

Journal Article > Commentary

Why 'Universal Precautions' are needed for medication lists.

Shane R. BMJ Qual Saf. 2016;25:731-732.

Despite the support for maintaining medication lists in electronic health records, these lists can contain and perpetuate errors. This commentary suggests that a set of standards are needed to ensure accuracy of electronic medication lists and reduce unnecessary or duplicate prescriptions in discharge instructions.

Tools/Toolkit > Toolkit

Patient Safety and Incident Management Toolkit.

Edmonton, AB: Canadian Patient Safety Institute. June 2015.

Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three-component toolkit provides resources that focus on incident management, patient safety management, and system factors to prevent and respond to failures or near misses.

Journal Article > Study

Best practices: an electronic drug alert program to improve safety in an accountable care environment.

Griesbach S, Lustig A, Malsin L, Carley B, Westrich KD, Dubois RW. J Manag Care Spec Pharm. 2015;21:330-336.

This study of a quality improvement initiative found that automated screening of prescribing data uncovered many potential adverse drug events. Prescribers were notified about these safety concerns, and almost 80% of these potential adverse drug events were resolved through prescription changes. The extent of patient harm which occurred or was averted was not reported. This work suggests that real-time data from electronic prescribing could be harnessed to improve patient safety, as others have suggested.

Grant > Grant Announcement

AHRQ Health Services Research Projects (R01).

US Department of Health and Human Services. Program Announcement No. PA-14-291.

This funding opportunity solicits large research projects and expresses Agency for Healthcare Research and Quality Research Portfolio priority areas of interest for extramural health services research, demonstration, dissemination, and evaluation grants. Applications for this funding will be accepted on a standard submission schedule through July 6, 2017.

Special or Theme Issue

Diagnostic Error in Medicine.

Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.

Articles in this special issue cover efforts to reduce diagnostic errors, including patient engagement and cognitive debiasing.

Audiovisual > Audiovisual Presentation

Can you read this drug label?

Gill L. Consumer Reports Health. June 2011.

This video reports on a sampling of prescriptions from major retail pharmacies that demonstrated gaps, inconsistencies, and lack of clarity in drug information distributed to patients with their medications.

Book/Report

Patient Safety: A Human Factors Approach.

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.

Newspaper/Magazine Article

'Use only as directed' isn't easy.

Landro L. Wall Street Journal. April 26, 2011:D1.

This newspaper article reports on factors contributing to the increasing number of consumer medication errors, including low literacy and confusing instructions, and discusses steps being taken to prevent such errors.

Journal Article > Study

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

Journal Article > Study

A human factors curriculum for surgical clerkship students.

Cahan MA, Larkin AC, Starr S, et al. Arch Surg. 2010;145:1151-1157.

A one-day course on human factors for medical students resulted in improved communication between the students and both patients and nurses.

Book/Report

The Safe Use Initiative and Health Literacy: Workshop Summary.

Vancheri C; Roundtable on Health Literacy; Institute of Medicine. Washington, DC: National Academies Press; 2010. ISBN-10: 0309159318.

This publication summarizes the content delivered at a workshop discussing the FDA's Safe Use Initiative and other medication label improvement programs.

Legislation/Regulation > Sentinel Event Alerts

Preventing violence in the health care setting.

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.

Journal Article > Study

Improving prescription drug warnings to promote patient comprehension.

Wolf MS, Davis TC, Bass PF, et al. Arch Intern Med. 2010;170:50-56.

Patients' inability to correctly interpret prescription drug instructions may result in devastating errors, such as one discussed in this AHRQ WebM&M commentary. Research on minimizing these errors has focused on mitigating the relationship between low health literacy and misunderstanding drug labels that has been demonstrated in prior research. This study found that merely simplifying the text of drug warnings improved comprehension, and addition of pictorial icons to the warnings further improved comprehension among adults with low or marginal health literacy. Prior research has also successfully used visual aids to improve medication adherence in chronic disease management. The role of health literacy in patient safety is discussed in an AHRQ WebM&M perspective and interview.

Journal Article > Review

Human factors in surgery: from Three Mile Island to the operating room.

D'Addessi A, Bongiovanni L, Volpe A, Pinto F, Bassi P. Urol Int. 2009;83:249-257.

This review provides background on human factors as a field of study in safety improvement and discusses its application to the operating theater and surgical team communication.

Journal Article > Study

Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.

Kiersma ME, Darbishire PL, Plake KS, Oswald C, Walters BM. Am J Pharm Edu. 2009;73:article 99.

This study implemented an educational curriculum focused on simulation activities and role playing to improve pharmacy students' awareness of the role that pharmacists play in error reduction. A past AHRQ WebM&M perspective discussed preparing future pharmacists to promote a culture of safety.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.

Perspectives on Safety > Perspective

Workarounds and Resiliency on the Front Lines of Health Care

with commentary by Anita L. Tucker, DBA, MS, Workarounds, August 2009

Frontline health care providers are challenged by poorly performing work systems. Required equipment is broken, patient medications are in the wrong dose, key information fails to get communicated, and essential supplies are out of stock.(

Newspaper/Magazine Article

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.

This article examines a case in which a health care professional faces criminal charges for a medication error. The piece discusses how criminalization of errors in health care could thwart broader efforts to learn from mistakes.

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