AHRQ Patient Safety Network

The Collection > Human Factors Engineering

PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (113)

•Diagnostic Errors (26)

•Identification Errors (44)

•Discontinuities, Gaps, and Hand-Off Problems (56)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (323)

•Medical Complications (86)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (122)

•Transfusion Complications (7)

•Psychological and Social Complications (11)

Origin/Sponsor

•Africa (1)

•Asia (12)

•Australia and New Zealand (28)

•Central and South America (2)

Resource Types

•Journal Article (490)

•Legislation/Regulation (18)

•Meeting/Conference (10)

•Newspaper/Magazine Article (133)

•Press Release/Announcement (10)

•Special or Theme Issue (28)

•Tools/Toolkit (6)

•Web Resource (10)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (117)

•Active Errors (214)

•Latent Errors (95)

•Near Miss (17)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (24)

•Medical Device Design (84)

•Medical Alarm Design (27)

•Checklists (128)

•Failure Mode Effects Analysis (5)

Clinical Areas

•Allied Health Services (3)

•Medicine (486)

•Nursing (108)

•Pharmacy (144)

Target Audience

•Health Care Providers (519)

•Health Care Executives and Administrators (609)

•Non-Health Care Professionals (289)

•Patients (53)

Setting of Care

•Hospitals (490)

•Psychiatric Facilities (1)

•Residential Facilities (10)

•Ambulatory Care (54)

•Outpatient Surgery (8)

•Patient Transport (5)

1 - 20 of 760

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SPECIAL OR THEME ISSUE

CMS 30-minute rule for drug administration needs revision.

ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.

STUDY

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.

STUDY

Association of interruptions with an increased risk and severity of medication administration errors.

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

STUDY

Medication Administration Time Study (MATS): nursing staff performance of medication administration.

Elganzouri ES, Standish CA, Androwich I. J Nurs Adm. 2009;39:204-210.

STUDY

The application of Aronson's taxonomy to medication errors in nursing.

Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.

REVIEW

Work interruptions and their contribution to medication administration errors: an evidence review.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

REVIEW

Fall prevention in hospitals: an integrative review.

Spoelstra SL, Given BA, Given CW. Clin Nurs Res. 2012;21:92-112.

STUDY

Going blank: factors contributing to interruptions to nurses' work and related outcomes.

Hall LM, Ferguson-Paré M, Peter E, et al. J Nurs Manag. 2010;18:1040-1047.

STUDY

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

Holden RJ, Scanlon MC, Patel NR, et al. BMJ Qual Saf. 2011;20:15-24.

STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

COMMENTARY

Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.

Nunnally ME, Bitan Y. J Patient Saf. 2006;2:124-131.

COMMENTARY

Interruptions and medication errors: part I.

Flanders S, Clark AP. Clin Nurse Spec. 2010;24:281-285.

COMMENTARY

Medication errors: don't let them happen to you.

Anderson P, Townsend T. Amer Nurs Today. March 2010;5:23-27.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

COMMENTARY

Medication room madness: calming the chaos.

Conrad C, Fields W, McNamara T, Cone M. J Nurs Care Qual. 2009;25:137-144.

NEWSPAPER/MAGAZINE ARTICLE

Prescription for success: don't bother nurses.

Colliver V. San Francisco Chronicle. October 28, 2009:A1.

COMMENTARY

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

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