Gosbee J
National Center for Patients Safety, Department of Veterans Affairs, Ann Arbor, MI 48106, USA.
Qual Saf Health Care. 2002 Dec;11(4):352-4. doi: 10.1136/qhc.11.4.352.
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.
本文所呈现的案例研究与分析表明了人因工程学（HFE）在患者安全方面的关键作用。人因工程学是一个用于高效且建设性思考的框架，其中包括有助于医疗团队进行患者安全分析（如根本原因分析） 的方法和工具。几十年来关于人因工程学的文献包含了有助于解决棘手患者安全问题和设计问题的理论与应用研究。文中给出了一个案例研究，该研究阐述了运输监测器中人因设计的薄弱环节。随后的分析突出了如何超越诸如培训等较为明显的促成因素，进而关注设计问题以及非正式规范的形成。文中提供了应对这些问题的一般性建议，并讨论了该案例特有的设计问题。
