Overview

In November 1999, the Institute of Medicine (IOM) released a report entitled, “To Err is Human: Building a Safer Health System,” in which they reported that between 44,000 and 98,000 patients die each year in U.S. hospitals due to medical errors.  Although this revelation took many in the health care community by surprise, there were individuals sounding the alarm in the past (e.g., Cooper, et al., 1978; Leape, 1994).  Moreover, Lucian Leape understood that methods from human factors might facilitate a decrease in medical errors when he stated:

“Can the lessons from cognitive psychology and human factors research that have been successful in accident prevention in aviation and other industries be applied to the practice of hospital medicine? There is every reason to think they could be” and “Error prevention strategies for the practice of medicine can be modeled after the theories of cognitive psychologists and human factors engineers” (Leape, 1994).

History of Health Care and Human Factors

The human factors discipline has been interested in understanding and mitigating the occurrence of human error within complex systems for decades (e.g., Norman, 1981; Reason, 1990).  With respect to health care, although research was performed within the discipline prior to the IOM report (e.g., Bogner, 1994; Cook, et al., 1998), it didn’t move to the forefront until the beginning of the 21st century.  Some of the actions that brought it into the spotlight included an editorial by the Human Factors and Ergonomics Society (HFES, 2000, February), an opinion piece by a former president of the Society (Woods, 2000, May), and the creation of a Task Force on Health Care (HFES, 2000, October).

The HFES has been a driving force in facilitating the advancement of health care human factors for a number of years. For instance, the Health Care Technical Group with 600+ members “…is interested in maximizing the contributions of human factors and ergonomics to medical systems’ effectiveness, patient safety and the quality of life for people who are sick or functionally impaired.  We seek to bring together people who share our interests.” Also, starting in 2012, the Society has held annual symposia that bring together human factors professionals from around the world to meet and share their latest research. The 2015 Symposium on Human Factors and Ergonomics in Health Care: Improving the Outcomes will feature health care topics in four tracks: Health-Care Provider and Patient Safety; Clinical and Consumer Health-Care IT; Medical and Drug Delivery Devices; and Clinical Care Settings.

Human Factors Areas of Focus in Health Care

The last 15+ years has seen significant human factors research and interventions focused on a variety of domains, topics, and targets, including:

• People (e.g., nurses, patients, pharmacists, physicians, technicians, etc.)

• Specialties (e.g., anesthesiology, critical care, emergency medicine, gynecology, nursing, pharmacy, radiology, surgery, etc.)

• Settings (e.g., emergency departments, home care, intensive care units, nursing homes, operating rooms, pharmacy departments, physician offices, etc.)

• Topics (e.g., build environment, care coordination, checklists, health information technology, infection prevention, medical devices, medication, organizational culture, patient satisfaction, simulation, teamwork, telemedicine, training, etc.)

More Work Is Needed

While human factors professionals have made great strides in assisting the health care community with mitigating the negative consequences of medical error, additional work is still needed.  As noted by Woods (2000, May), “Health care is an opportunity for human factors, but only if we are up to the sacrifices involved in building, extending, and deepening the ways we can help people create safety” (p. 5). I have no doubt that the our professionals are up to the challenge of tacking this worthy endeavor and working with others to provide practical solutions that can be implemented by the health care community.

To Learn More

Interested readers are encouraged to review the following resources to learn how human factors researchers and practitioners have assisted with decreasing medical errors and increasing patient safety within health care while also increasing efficiency and decreasing overall costs.

Books

• Carayon, P. (2011).  Handbook of human factors and ergonomics in health care and patient safety (2nd ed).  Boca Raton, FL: CRC Press.
• Dekker, S. (2011). Patient safety: A human factors approach. Boca Raton, FL: CRC Press.
• Reason, J. (2008). The human contribution. Burlington, VT: Ashgate Publishing Company.
• Salas, E., Frush, K., Baker, D.P., Battles, J.B., King, H.B., & Wears, R.L. (2013). Improving patient safety through teamwork and team training. New York, NY: Oxford University Press.
• Woods, D.D., Dekker, S., Cook, R., Johannesen, L., & Sarter, N. (2010). Behind human error. Burlington, VT: Ashgate Publishing Company.

Chapters

• Carayon, P., Alyousef, B., & Xie, A. (2012). Human factors and ergonomics in health care. In Gavriel Salvendy (Ed.), Handbook of Human Factors and Ergonomics, 4th (pp. 1574-1595).
• Morrow, D., North, R., & Wickens, C.D. (2005).  Reducing and mitigating human error in medicine.  In R.S. Nickerson (Ed.), Reviews of Human Factors and Ergonomics, Vol. 1 (pp. 254-296).  Santa Monica, CA: Human Factors and Ergonomics Society.

Reviews

• Morrow, D.G. (Ed.). (2013). Reviews of Human Factors and Ergonomics (Vol. 8). Santa Monica, CA: Human Factors and Ergonomics Society.

Journals

• Bagnara, S. (2007).  Patient safety – An old and a new issue.  Theoretical Issues in Ergonomics Science, 8, 365-369.
• Barach, P. (2007).  A team-based risk modification programme to make health care safer.  Theoretical Issues in Ergonomics Science, 8, 481-494.
• Buckle, P., Clarkson, P.J., Coleman, R., Ward, J., & Anderson, J. (2006).  Patient safety, systems design and ergonomics.  Applied Ergonomics, 37, 491-500.
• Carayon, P., Wetterneck, T.B., Rivera-Rodriguez, A.J., Hundt, A.S., Hoonakker, P., Holden, R., & Gurses, A.P. (2014). Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics, 45, 14-25.
• Friesdorf, W., Buss, B., & Marsolek, I. (2007).  Patient safety by treatment standardization and process navigation – A systems ergonomics management concept.  Theoretical Issues in Ergonomics Science, 8, 469-479.
• Healey, A.N., & Vincent, C.A. (2008).  The systems of surgery.  Theoretical Issues in Ergonomics Science, 8, 429-443.
• Karsh, B., Holden, R.J., Alper, S.J., & Or, C.K.L. (2006).  A human factors engineering paradigm for patient safety: Designing to support the performance of the healthcare professional.  Quality and Safety in Health Care, 15 (Suppl I), 59-65.
• Leape, L.L. (2004, Summer).  Human factors meets health care: The ultimate challenge.  Ergonomics in Design, 6-12.
• Russ, A.L., Fairbanks, R.J., Karsh, B., Militello, L.G., Saleem, J.J., & Wears, R.L. (2013). The science of human factors: Separating fact from fiction. BMJ Quality and Safety, 22, 802-808.
• Salad, E., Baker, D., King, H., & Battles, J. (2006).  Special section commentary: Opportunities and challenges for human factors and ergonomics in enhancing patient safety.  Human Factors, 48, 1-4.
• Salas, E., Rosen, M.A., & King, H. (2007).  Managing teams managing crises: Principles of teamwork to improve patient safety in the emergency room and beyond.  Theoretical Issues in Ergonomics Science, 8, 381-394.
• Schutz, A.L., Counte, M.A., & Meurer, S. (2007).  Assessment of patient safety research from an organizational ergonomics and structural perspective.  Ergonomics, 50, 1451-1484.
• Weaver, S.J., Salas, E., & King, H.B. (2011). Twelve best practices for team training evaluation in health care. The Joint Commission Journal on Quality and Patient Safety, 37, 341-349.

Proceedings

• Proceedings of the 2014 International Symposium on Human Factors and Ergonomics in Health Care: Leading the Way
• Proceedings of the 2013 International Symposium on Human Factors and Ergonomics in Health Care: Advancing the Cause
• Proceedings of the 2012 Symposium on Human Factors and Ergonomics in Health Care: Bridging the Gap

Websites

• Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network
• HFES Health Care Technical Group
• HFES Health Care Symposia

References

Bogner, M.S. (Ed.). (1994). Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates.

Cook, R.I., Woods, D.D., & Miller, C. (1998).  A tale of two stories: Contrasting views of patient safety. Boston, MA: National Patient Safety Foundation.

Cooper, J.B., Newbower, R.S., Long, C.D., & McPeek, M. (1978).  Preventable anesthesia mishaps: A study of human factors.  Anesthesiology, 49, 399-406.

Human Factors and Ergonomics Society (2000, February).  Patient safety and human factors/ergonomics.  Human Factors and Ergonomics Society Bulletin, 43(2), 1-2.

Human Factors and Ergonomics Society (2000, October).  Human factors and patient safety, continued.  Human Factors and Ergonomics Society Bulletin, 43(10), 1-2.

Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.). (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press.

Leape, L.L. (1994).  Error in medicine.  The Journal of the American Medical Association, 272, 1851-1857.

Norman, D.A. (1981).  Categorization of action slips.  Psychological Review, 88, 1-15.

Reason, J. (1990).  Human error. New York, NY: Cambridge University Press.

Woods, D.D. (2000, May).  Patient safety and human factors opportunities.  Human Factors and Ergonomics Society Bulletin, 43(5), 1; 4-5.