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An Overlooked Alliance: Using Human Factors Engineering to Reduce Patient Harm

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Background: Although human factors engineering (HFE) is considered only in relationship to the design of medical devices or information systems technology, human factors issues arise in many aspects of work in health care organizations.

HFE Analysis: In one scenario, the resuscitation stretcher would not pass through the ED door closest to radiology. Many clinical work spaces were never formally designed for the work currently being performed in them; instead, they were adapted from existing space originally designed for a different use. In a second scenario, infusion pump malfunction was not apparent. The patient experienced a near miss secondary to poor design; users thought that the infusion pump had been turned off when it was not.

Recommendations: Health care can significantly benefit from the incorporation of HFE into the work place. Introductory classes in medical and nursing schools on HFE will assist students in detecting HFE related issues, making them less likely to suffer with them or overlook them once in clinical practice. More extensive training for patient safety and risk managers, that is, at a minimum, a certificate-level course from an HFE program, would enhance case and root cause analyses since these issues are rarely factored in.

Conclusion: Collaboration with HFE experts and use of HFE principles may not make health care foolproof, but it will make it less dependent on improvisation and ingenuity to protect patients from the system's vulnerabilities.

Document Type: Research Article

Publication date: August 1, 2004

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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