Abstract
The case study and analyses presented here illustrate the crucial role of human factors engineering (HFE) in patient safety. HFE is a framework for efficient and constructive thinking which includes methods and tools to help healthcare teams perform patient safety analyses, such as root cause analyses. The literature on HFE over several decades contains theories and applied studies to help to solve difficult patient safety problems and design issues. A case study is presented which illustrates the vulnerabilities of human factors design in a transport monitor. The subsequent analysis highlights how to move beyond the more obvious contributing factors like training to design problems and the establishment of informal norms. General advice is offered to address these issues and design issues specific to this case are discussed.
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Selected References
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- Burlington D. B. Human factors and the FDA's goals: improved medical device design. Biomed Instrum Technol. 1996 Mar-Apr;30(2):107–109. [PubMed] [Google Scholar]
- Chassin Mark R., Becher Elise C. The wrong patient. Ann Intern Med. 2002 Jun 4;136(11):826–833. doi: 10.7326/0003-4819-136-11-200206040-00012. [DOI] [PubMed] [Google Scholar]
- Moloney J. T., Downey G. What are we really monitoring? Anaesth Intensive Care. 1994 Jun;22(3):320–321. [PubMed] [Google Scholar]
- Ramundo G. B., Larach D. R. A monitor with a mind of its own. Anesthesiology. 1995 Jan;82(1):317–318. doi: 10.1097/00000542-199501000-00049. [DOI] [PubMed] [Google Scholar]
- Shojania Kaveh G., Duncan Bradford W., McDonald Kathryn M., Wachter Robert M. Safe but sound: patient safety meets evidence-based medicine. JAMA. 2002 Jul 24;288(4):508–513. doi: 10.1001/jama.288.4.508. [DOI] [PubMed] [Google Scholar]
- Vincent C., Taylor-Adams S., Chapman E. J., Hewett D., Prior S., Strange P., Tizzard A. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000 Mar 18;320(7237):777–781. doi: 10.1136/bmj.320.7237.777. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Welch D. L. Human error and human factors engineering in health care. Biomed Instrum Technol. 1997 Nov-Dec;31(6):627–631. [PubMed] [Google Scholar]
- Welch D. L. Human factors in the health care facility. Biomed Instrum Technol. 1998 May-Jun;32(3):311–316. [PubMed] [Google Scholar]