The application of HFE in health care and patient safety is not new. In the late 1950’s, Al Chapanis, one of the founders of the human factors discipline, and his colleagues at the Johns Hopkins University conducted a study of medication errors in hospitals (Chapanis & Safrin, 1960
; Safren & Chapanis, 1960a
). Using the critical incident technique method, they identified a total of 178 medication errors over a 7-month period that were classified in 7 categories (e.g., wrong patient, wrong dose of medication, omitted medication) (Safren & Chapanis, 1960a
). Most (90%) causes of the medication errors fell in the following five categories: failure to follow required checking procedures, misreading or misunderstanding written communication, transcription errors, medicine tickets misfiled in ticket box, and computational errors (Safren & Chapanis, 1960a
). Even though this research led to several recommendations for preventing medication errors, such as improving written communication (e.g., legibility of handwriting), medication procedures (e.g., double checking) and the working environment (e.g., design of the nurse station and of the medication preparation area) (Safren & Chapanis, 1960b
), healthcare organizations have paid very little attention to this study’s recommendations.
In 1996, a special section of the Human Factors
journal on human factors in health care was published under the leadership of Bogner (1996)
. Several papers published in the special section address HFE issues related to patient safety, including the relationship between noise and pharmacists’ accuracy in filling prescriptions (Flynn, et al., 1996
) and team coordination in emergency care (Xiao, Hunter, Mackenzie, Jefferies, & Horst, 1996
HFE is relevant for various functions within healthcare institutions to help solve many different kinds of problems, including patient safety (Carayon, 2005
). For instance, HFE methods for analyzing the usability of technologies can be used by information technology staff in healthcare organizations that are involved in the design of computerized provider order entry, electronic medical record systems and other information technologies. HFE has been incorporated in the decision-making process used by a Canadian hospital for purchasing infusion pumps (Ginsburg, 2005
). HFE has been applied to improve the design of healthcare technologies, such as PCA (patient controlled analgesia) pumps (Lin, Vicente, & Doyle, 2001
) and infusion pumps (Zhang, Johnson, Patel, Paige, & Kubose, 2003
), and the design of healthcare facilities (Reiling, et al., 2004
). The incident reporting system for intensive care units created by Wu, Pronovost and colleagues (Wu, Pronovost, & Morlock, 2002
) includes collection of data on various work system elements and HFE. Larsen and colleagues (2005)
applied HFE principles to the redesign of pharmacy-generated medication labels. These examples show the diversity of patient safety problems that can benefit from HFE. However, there is still a lot that needs to be learned about the applicability and application of HFE in healthcare organizations (Carayon, 2005
Even though research on and applications of HFE for patient safety exist (Carayon, 2007
), numerous HFE applications can be considered as innovations in the context of healthcare organizations. Those HFE applications can be categorized as (1) use of HFE tool or method (e.g., a healthcare organization performs a usability evaluation of a medical device or conducts a task analysis to identify sources of workload and error), (2) increase of general HFE knowledge provided to various staff of a healthcare organization (e.g., patient safety officers, risk managers and quality improvement staff of a healthcare organization are trained in HFE), and (3) recruitment of an HFE professional by a healthcare organization. provides examples for each of these three types of HFE applications and innovations for patient safety. The HFE innovations for patient safety can also be categorized according to the three domains of HFE as defined by the International Ergonomics Association (2000)
: (1) physical ergonomics, such as physical ergonomic design of hospital facilities for enhancing hand hygiene practices, (2) cognitive ergonomics, such as assessment of workload, and (3) organizational ergonomics, such as teamwork (see for additional examples).
Domains of Human Factors and Ergonomics (HFE) and their Relationships to HFE Innovations and Patient Safety
To facilitate and support the application of HFE in healthcare organizations, we can consider HFE as an innovation whose diffusion, dissemination, implementation and sustainability need be understood and specified. Diffusion is the passive spread of innovations and changes, whereas dissemination involves active and planned efforts to convince target groups to adopt an innovation. The implementation of the innovation includes active and planned efforts to incorporate an innovation within an organization. An innovation is sustained if it is institutionalized and routinely used within an organization. In this paper, we use the conceptual model of innovation developed by Greenhalgh et al. (2004)
to examine the potential challenges related to the use of HFE innovations in health care and patient safety. To our knowledge, Greenhalgh et al. (2004)
conducted one of the most comprehensive reviews of research on innovations, which led to the development of a systemic model of innovation that is used in this paper. Other models of innovation exist, such as the well-known Diffusion of Innovation model (E. M. Rogers, 1962
). However, these other models of innovation tend to focus on limited aspects of innovation. For instance, Rogers’ (1962)
Diffusion of Innovation model addresses the stages of innovation adoption. The review of the innovation literature by Wejnert (2002)
discusses characteristics of innovations, characteristics of innovators and the environmental context, but ignores the process and dynamic issues related to innovation, such as adoption, assimilation, implementation and sustainability. In addition to its comprehensiveness, the literature review conducted by Greenhalgh and her colleagues targeted health care as a domain; therefore, their systemic model of innovation is relevant to our discussion of HFE innovations in patient safety.
provides a graphical representation of how we adapted the Greenhalgh et al. (2004)
model of innovation to HFE applications. In order for the HFE application to be implemented in a healthcare organization, we need to examine the organizational characteristics (antecedents) that favor innovations, as well as the extent to which the organization is ready to adopt the innovation. Once the organization has decided to adopt the innovation, the implementation and sustainability of the HFE application occur. The impact of the HFE innovation on patient safety can then be evaluated and monitored. A number of people and organizations within (e.g., boundary spanners) and outside of the healthcare organization can influence the diffusion and dissemination of HFE in healthcare organizations. There is also a wider environment that can influence HFE applications in health care and patient safety. Each component of the innovation model is discussed separately in the following section of the paper.