Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Human Factors Engineering"

1 - 20 of 201 results
Download Selected Citations

Show: 20 | 50 | 100

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.

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.

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 > 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.

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.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

This monthly selection of medication error reports includes information about the risks of cutting medication patches, describes examples of drug name confusion, and explains the importance of indicating the purpose for the medication on prescriptions.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:960-964.

This monthly selection reports on pump programming errors that led to overdoses of patient-controlled analgesia (PCA), miscommunication regarding dose and indication for alteplase, and a warning to not use empty prelabeled syringes.

Journal Article > Commentary

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.

Newspaper/Magazine Article

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.

Journal Article > Commentary

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

This article discusses hospital compliance with National Patient Safety Goals regarding medication safety and describes strategies to improve anticoagulant administration safety.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:257-260.

This monthly selection includes reports of a near miss when using a medication-reconciliation form as an order sheet, epidural tubing mistakenly utilized for an intravenous medication, a topical medication given orally, and problems with monitoring temperatures of medication refrigerators.

Newspaper/Magazine Article

Hospitals target risks of color wristbands.

Landro L. Wall Street Journal. April 4, 2007:D5. 

This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:284–287.

This monthly selection of medication error reports provides examples of problems related to medication misadministration, drug shortages, and the appropriate use of the "five rights" of medication delivery.

Journal Article > Study

A prospective study of patient safety in the operating room.

  • Classic

Christian CK, Gustafson ML, Roth EM, et al. Surgery. 2006;139:159-173.

This study used a multidisciplinary team of human factors experts and surgeons to identify critical system features that affect patient safety. The observational team carefully followed and recorded events from 10 general surgery cases. Primary findings suggested deficiencies in communication and information flow as well as competing tasks that created poor team performance. The authors suggest this methodology may provide an effective mechanism to identify patient safety issues and potential areas for intervention.

Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Commentary

Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.

Carroll C, Hassanin A. JAMA Intern Med. 2017 Apr 24; [Epub ahead of print].

Geriatric patients are particularly vulnerable to adverse drug events due to comorbidities, complicated care plans, and polypharmacy. This commentary describes how using STOPP criteria and performing indication mapping can help reduce polypharmacy and improve patient safety.

Journal Article > Study

Introductions during time-outs: do surgical team members know one another's names?

Birnbach DJ, Rosen LF, Fitzpatrick M, Paige JT, Arheart KL. Jt Comm J Qual Patient Saf. 2017;43:284-288.

Communication failures in the operating room are a patient safety issue, and knowing other team members' names may help reduce hierarchies that contribute to errors. Introductions are the first step in the surgical time-out in the World Health Organization Surgical Safety Checklist. However, this study—conducted in the operating rooms of three teaching hospitals—suggests that team members often do not know each other's names and may not view introductions as important for maintaining safety.

Back to Top