Human Factors and Patient Safety

“Our first recommendation,” Woods stated, “is that the research program be built from the beginning as a substantive partnership between human performance specialties and health care specialties.” Emphasizing the unique perspective of human factors on medical error, Woods stated that errors that are documented in, among other things, the recent Institute of Medicine report, “To Err Is Human,” are the domain of the cognitive, social, and behavioral sciences (of which human factors is a part), not of physiology, disease processes, or therapeutic interventions. “Where you are puzzled by erratic people, we see common patterns in problem solving and cooperative work.”

Application of human factors research in other high-risk industries, such as nuclear power, “seems to be far too rare in medical devices and computer systems,” Woods said. “We are concerned that the calls for more use of integrated computerized information systems to reduce error could introduce new and predictable forms of error unless there is a significant investment in user-centered design.

“The research program on patient safety must look ahead at the changes affecting safety in health care. The research base on human performance can help you forecast challenges to safety and develop the programs to anticipate needs.”