An overlooked alliance: using human factors engineering to reduce patient harm.

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 workplace. 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 fool-proof, but it will make it less dependent on improvisation and ingenuity to protect patients from the system's vulnerabilities.