Human factors engineering in healthcare systems: the problem of human error and accident management

This paper discusses some crucial issues associated with the exploitation of data and information about health care for the improvement of patient safety. In particular, the issues of human factors and safety management are analysed in relation to exploitation of reports about non-conformity events and field observations. A methodology for integrating field observation and theoretical approaches for safety studies is described. Two sample cases are discussed in detail: the first one makes reference to the use of data collected in the aviation domain and shows how these can be utilised to define hazard and risk; the second one concerns a typical ethnographic study in a large hospital structure for the identification of most relevant areas of intervention. The results show that, if national authorities find a way to harmonise and formalize critical aspects, such as the severity of standard events, it is possible to estimate risk and define auditing needs, well before the occurrence of serious incidents, and to indicate practical ways forward for improving safety standards.