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Understanding Adverse Events: A Human Factors Framework.


In: Hughes RG, editor.


Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 5.
Advances in Patient Safety.


The complex and demanding clinical environment of nurses can be made a bit more understandable and easier in which to deliver care by accounting for a wide range of human factors concerns that directly and indirectly impact human performance. Human factors is the application of scientific knowledge about human strengths and limitations to the design of systems in the work environment to ensure safe and satisfying performance. A human factors framework such as that portrayed in Figure 1 helps us become aware of the salient components and their relationships that shape and influence the quality of care that is provided to patients. The concept of human error is a somewhat loaded term. Rather than falling into the trap of uncritically focusing on human error and searching for individuals to blame, a systems approach attempts to identify the contributing factors to substandard performance and find ways to better detect, recover from, or preclude problems that could result in harm to patients. Starting with the individual characteristics of providers such as their knowledge, skills, and sensory/physical capabilities, we examined a hierarchy of system factors, including the nature of the work performed, the physical environment, human-system interfaces, the organizational/social environment, management, and external factors. In our current fragmented health care system, where no single individual or entity is in charge, these multiple factors seem to be continuously misaligned and interact in a manner that leads to substandard care. These are the proverbial accidents in the system waiting to happen. Nurses serve in a critical role at the point of patient care; they are in an excellent position to not only identify the problems, but to help identify the problems-behind-the-problems. Nurses can actively practice the tenets of high-reliability organizations. It is recognized, of course, that nursing cannot address the system problems all on its own. Everyone who has a potential impact on patient care, no matter how remote (e.g., device manufacturers, administrators, nurse managers), needs to be mindful of the interdependent system factors that they play a role in shaping. Without a clear and strong nursing voice and an organizational climate that is conducive to candidly addressing system problems, efforts to improve patient safety and quality will fall short of their potential.

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