Human Factors Research in Patient Safety: A Candid Assessment

Five panelists, playing active research roles in the Agency for Healthcare Research and Quality's patient safety research initiative, present their views on challenges to human factors research for enhancing patient safety. Bogner advocates a systems structure for linking the findings of various research projects so that the missing pieces of the patient safety puzzle can serve as fruitful targets for subsequent research. Carayon adopts a macroergonomic framework for designing interventions to clinical work systems while Cook focuses on the complexity that underlies configurable clinical devices. With respect to anesthesia and critical care, Weinger cites the successful use of task analysis, workload assessment, and video analysis, yet notes challenges regarding concerns about patient privacy, disruption of patient care, and cultural barriers. Xiao cites impressive HF/E work on team coordination and performance shaping factors and sees the need for greater use of video and information technology to improve institutional learning and coordination of patient care.