Table 1. Potential systems improvements for patient safety utilizing principles of human factors engineering

Use of automated machines with appropriate human interactions preserved

Use of procedural simplifications and standardizations (e.g., protocols, checklists, standardized data displays)

Use of fail safes (e.g., device defaults to the safest mode)

Use of constraints (e.g., minimizing number of medication choices and dose ranges on pre-printed order forms)

Use of forcing functions (e.g., pharmacy computers that will not fill an order unless patient allergies, weight, height are entered)

Use of affordances and natural mapping (e.g., arranging numerical keypads on medical devices in the same pattern as computer or calculator keypads)

Use of buffers and redundancies to provide backup and recovery opportunities (e.g., reminders, double checks)

Creation of an environment that is conducive to work physically (e.g., optimal lighting and space) and psychologically (e.g., work schedule)

Improvement of communication and coordination within health care teams

Implementation of stringent personnel training, examination and certification

Data from Kohn et al. [1], Cohen [8], and Institute of Medicine [14].