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

Area of Science:

• Human Factors Engineering (HFE)
• Healthcare Systems Engineering
• Patient Safety Science

Background:

• Human factors engineering (HFE) is often narrowly viewed as solely related to medical device or information technology design.
• HFE principles are applicable across numerous facets of healthcare operations, extending beyond traditional technological applications.
• Many clinical workspaces are retrofitted or adapted from original designs not intended for current healthcare functions.

Observation:

• Workplace design flaws can lead to critical incidents, such as equipment incompatibility with physical spaces (e.g., resuscitation stretchers and ED doors).
• Poorly designed medical equipment can create hazardous situations, as illustrated by an infusion pump malfunction where users misinterpreted its status, resulting in a near-miss event.
• Clinical environments often rely on workarounds and improvisation due to inherent system vulnerabilities, rather than standardized, human-centered design.

Findings:

• Healthcare organizations can achieve substantial improvements by integrating HFE principles into their operational frameworks.
• Educational initiatives, including introductory HFE courses in medical and nursing programs, empower future clinicians to identify and mitigate HFE-related risks.
• Specialized HFE training for patient safety and risk managers is essential for improving root cause analyses, as HFE factors are frequently overlooked.

Implications:

• Implementing HFE principles can reduce healthcare's reliance on user ingenuity and improvisation to compensate for system flaws.
• Proactive integration of HFE into healthcare design and practice is vital for enhancing patient safety and operational efficiency.
• A collaborative approach involving HFE experts and the adoption of HFE methodologies can create more robust and safer healthcare systems.