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; United States; 3. Good health; 03 medical and health sciences; 0302 clinical medicine; 13. Climate action; Humans; 0501 psychology and cognitive sciences; Ergonomics; Patient Safety; Delivery of Health Care

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.