Challenges And Opportunities For Improving Patient Safety Through Human Factors And Systems Engineering

• DOI: 10.1377/hlthaff.2018.0723
• Publication Date: 2018-11-05T20:56:20Z
• Authors: Pascale Carayon; Abigail Wooldridge; Bat-Zion Hose; Megan Salwei; James Benneyan
• Keywords: Medication Systems, Hospital; Medical Errors; Quality Assurance, Health Care; 05 social sciences; Humans; 0501 psychology and cognitive sciences; Ergonomics; Patient Safety; Delivery of Health Care; United States; 3. Good health

Despite progress on patient safety since the publication of the Institute of Medicine's 1999 report, To Err Is Human, significant problems remain. Human factors and systems engineering (HF/SE) has been increasingly recognized and advocated for its value in understanding, improving, and redesigning processes for safer care, especially for complex interacting sociotechnical systems. However, broad awareness of HF/SE and its adoption into safety improvement work have been frustratingly slow. We provide an overview of HF/SE, its demonstrated value to a wide range of patient safety problems (in particular, medication safety), and challenges to its broader implementation across health care. We make a variety of recommendations to maximize the spread of HF/SE, including formal and informal education programs, greater adoption of HF/SE by health care organizations, expanded funding to foster more clinician-engineer partnerships, and coordinated national efforts to design and operationalize a system for spreading HF/SE into health care nationally.