Part 2 b . Practices Designed To Improve Overall System / Multiple Targets

Many patient safety incidents are related to lack of attention to human factors and ergonomics (HFE) in the design and implementation of technologies, processes, workflows, jobs, teams and sociotechnical systems. For instance, a systems analysis of medication errors 1 identified a range of proximal causes of medication errors, such as rule violations, memory slips and lapses, poor communication with other services, and incorrect pump programming caused by poor design of the pump interface. Lack of attention to HFE in areas such as technology design can contribute to medication errors and preventable adverse drug events. The Institute of Medicine (IOM) report on Medication Errors 2 emphasizes the need for addressing HFE issues, such as the design of medication labels and packages, and the design of medication administration technologies (e.g., infusion pump). A study by Han et al. 3 in a pediatric hospital showed an increase in mortality rates after the implementation of Computerized Provider Order Entry (CPOE); many factors that contributed to the increase were related to HFE. For instance, the design of the CPOE interface required about 10 clicks per order, thus significantly increasing time needed to enter orders. The poor usability of the CPOE system and its lack of integration with clinician workflow contributed to delays in patient care that were a major factor in the increased mortality rate after CPOE implementation. The recent IOM report on Health IT and Patient Safety 4 clearly indicates the need for HFE in the design, implementation and use of health IT. The report proposes a sociotechnical approach that emphasizes the need for health IT to support clinical workflows. Increased cognitive workload associated with the implementation and use of health IT and lack of usability of health IT are two HFE issues associated with patient safety incidents highlighted in the report. A systematic review showed how environmental hazards can contribute to patient safety incidents such as patient falls. 5 For instance, the use of bedrails can contribute to patient falls by contributing to entrapment injuries. These studies provide evidence for the importance of HFE in patient safety; they highlight the range of physical, cognitive and organizational HFE issues that can contribute to patient safety incidents. There are many other examples of how lack of attention to HFE contributes to patient safety incidents. For instance, a fatal medication error occurred on July 5, 2006 at St. Mary's hospital in Madison, WI: An epidural penicillin …