Reflective Journal – Human Factors

Reflective Journal – Human Factors

(In 400 Words)

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As a result of participating in the human factors exercise, you will be able to:

1. Identify human factors in everyday settings.

2. State how such factors contribute to errors.

3. Develop strategies to minimize or prevent error.


For the purposes of this exercise, you should have completed four lessons offered by the IHI Open School: Patient Safety 101, Lesson 1 and Patient Safety 102, Lessons 1-3.

For more information refer to  IHI Human Factor  document.


1. Visit any of the following locations:

· Restaurant · Coffee shop
· Transportation system · Retail store
· Hotel · Major intersection
· Library · Health care setting

2. Using the information from IHI and the IHI Human Factor document: Can you identify human factor issues that create opportunities for errors?

· What processes rely on memory?

· What tools can be used to eliminate the need to rely on memory?

· How well would the processes you observe work if the individual involved were tired? Distracted?

· What type of errors might occur? How would someone know if these error(s) had occurred?

· Are there steps that can be skipped or bypassed? Is this a good or bad design? Why?

· Would a new person be likely to make more, less or the same number of errors as an experienced person? Why?

· Are there systems in place – or that should be in place – to minimize the opportunities for error?

2.  Write a  Reflective Journal   entry analyzing a day-to-day activity, where errors might happen, and how to prevent errors.



Human Factors Engineering

A sixty-five-year-old gentleman experiences a cardiac arrest on Day 2 of his hospitalization on the medical-surgical nursing unit. A code blue is called by the nursing staff and the code team of the hospital arrives in the patient’s room to initiate resuscitation. However, when the code team tries to hook the patient to their portable monitor, the leads on the monitor are incompatible with the stickers on the patient. This example highlights the interaction between health care providers, equipment, and environment which can lead to error(s).

The science of human factors is an “engineering discipline that places people into sociotechnical systems to minimize human error and maximize efficiency” (Clapper, 2019, p. 274). Human factors engineering (HFE) is the discipline that identifies safety problems and designs potential solutions, e.g. equipment design. As a result, attempts are made to design systems that optimize safety, and reduce the risk of harm and error. Carayon et al. (2018) asserts that it also brings a systems perspective to patient safety by stressing the analyzes of care processes. In essence, HFE involves the application of human factors knowledge to the design of equipment, products, services and systems.


The International Ergonomics Association defines human factors (or ergonomics) using the following definition:

Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.

This definition was also adopted by the Human Factors and Ergonomics Society.

HFE has been used extensively in a variety of industries including the aviation, oil and gas, automotive, defense and the nuclear sector. More recently, human factors was first introduced to anesthesia in the redesign of anesthesia equipment to reduce the risk of injury and/or death in the operating room. Waterson and Catchpole (2016) assert progress has been made in integrating HFE in healthcare; however, more investment is required to promote HFE and its benefits and value for patient safety.

Human factors is simply “designing to fit people” (Norris, 2009, p. 204). In health care, human factors is essential to best practice and process design because it “builds in the capabilities and limitations of humans in the workforce” (Fryer, 2012, p. 56). Fryer goes on to state nurses must recognize the precursors and antecedent human factors and study their effects in redesigned systems. There must be a ‘good fit’ between people and the system(s). Not being able to adjust the chairs at the nursing station to the right position or locate the stop button for the alarm on the patient’s monitor are examples of a ‘poor fit’. It is essential that system design reflects human behavior. Human factors contribute to the ‘fit’ of system design.

Root cause analysis including the fishbone technique, incident decision trees, team work, safety culture measurements such as a blame-free environment and acknowledgement of high-risk, and the procurement of medical devices and equipment are examples of tools available to help us to apply human factors in order to improve patient safety.

The YouTube video titled, Human factors: As seen on TV introduces us to human factors by simply turning on our television. In essence, “human factors … is about how people interact with the world, when doors tell you if they can be opened or not, user-friendly technology, people and machines working together, and information that is timely and useful.” The video was produced by the San Jose State University, Human Factors and Ergonomics Society (HFES) Student Chapter in 2011.


The Introduction to Human Factors Engineering video presentation describes how HFE can be applied to various engineering disciplines including the aviation and health care industries. One example from health care, as shared in the video, is in the improved designed of the defibrillator. The improved design included operator guidance with more an intuitive interface and user prompts to avoid accidental shutdown of the defibrillator.


Hignett et al. (2015) describe the importance of integrating HFE and quality improvement science to produce practical approaches to the improvement of healthcare. HFE studies a problem by examining the people and their interactions with each other as well as the system, itself to redesign tasks, interfaces and system. Quality improvement science examines processes within a system to identify variation and then implement change(s)/test(s) of change to achieve the desired outcome.

Waterson and Catchpole (2015) describe a human factors and ergonomics systems model using an ‘onion’ metaphor to highlight the various factors influencing better work performance and work design. These factors are related to individuals, technology and the wider organization. “HFE scientists and practitioners apply a holistic approach in order to understand complex interacting systems and subsystems involving people” (p. 480). See Figure 1.

The Joint Commission (2015) provides a list of questions to ask when considering how human factors affects the patient safety system.

Using Human Factors Questions to Analyze the System

1. What are the goals? Do end users/teams have a shared goal, shared understanding of that goal, tools, and resources to achieve the goal?

1. Is information available, timely, perceptible, and understandable?

1. Is there unnecessary complexity among work processes and technology or opportunities to standardize, simplify, streamline?

1. How is the system designed with cognitive considerations such as attention, recognition, memory, and cognitive biases in mind?

1. Are the environment and tools supportive of the various end users/teams and work being performed? Are they intuitively designed or designed for error? Is the ambient setting such that information can be effectively seen, heard, communicated?

1. What are the organizational goals, priorities, and incentives? Does the organization provide the necessary resources, conditions, leadership, and culture to perform work safely? How are end users empowered to recognize and report potential hazards and events? How are “things that go well” recognized and understood?



Human (User)-Centered Design

Earlier in the course, you were introduced to the following four commonly used quality improvement models:

· Model for Improvement

· Plan-Do-Study-Act (PDSA) Cycle

· Lean, or the Toyota Production System

· Six Sigma

These models guide the process of quality improvement and have core commonalities.

Human (user)-centered design is another quality improvement model. Although the previously discussed models originated from the manufacturing industry, design models are derived from architecture, product development, and fashion industries. Human-centered design in health care incorporates a variety of concepts and practices which include HFE, processes with end users, and the process of co-creating devices and spaces (Jaffe et al., 2019). Examples of human centered design include designing a 15-minute “huddle” structure, heart monitor for people with atrial fibrillation, and new type of prosthetic device for amputees.

Although the steps in the design process may vary slightly, Jaffe et al. (2019) describe the steps of the design process:


The two key steps in the human-centered design model are building empathy and creating prototypes. It is all about empathy. Empathy puts the user first and helps you create tangible products and/or services for the user. Prototypes are based on the best ideas. They can be paper sketches, physical models, storyboards, or digital to name, but a few. Most often, prototypes are low-cost, small-scales of your solution(s). describes human-centered design as a “creative approach to problem solving”. It is a process that begins with the end user, the people you are designing for and ends with solutions, useful and usable products and services to meet the needs of the end user. In the following video presentation answers the question, What is human-centered design?


Human Factors: Personal Protective Equipment during the COVID-19 Pandemic

Hignett et al. (2021) conducted an online survey, between April 4 and May 8, 2020, to better understand how PPE changes clinical tasks by focusing on human factors/ergonomic issues in the U.K. The researchers included a wide range of PPE including face cover, body cover and gloves. Four hundred and five responses were received. Human factor/ergonomic issues with the PPE included visual difficulties with safety glasses and visors, problems with communication and hearing alarms, impaired hand (fine motor) function, and restricted reaching (gross motor) activities. Surviving PPE theme included injuries and overheating. Based on the findings, more human factors/ergonomic research was recommended to improve the functional design of PPE to better support the health care provider.



Lesson 5 of 6

Carayon, P., Wooldridge, A., Hose, B-Z, Salwei, M., & Benneyan, J. (2018). Challenges and opportunities for improving patient safety through human factors and systems engineering. Health Affairs, 37(11), 1862-1869.  (Library Link)

Clapper, C. (2019). Safety science and high reliability organizing. In D.B. Nash, M.S. Joshi, E.R. Ransom, & S.B. Ransom (Eds.). The healthcare quality book: Vision, strategy, and tools (4th ed., pp. 253-278). Health Administration Press.

Drews, F.A., Visnovsky, L.C., & Mayer, J. (2019). Human factors engineering contributions to infection prevention and control. Human Factors, 61(5), 693-701.

Fryer, L.A. (2012). Human factors in nursing: The time is now. Australian Journal of Advanced Nursing, 30(2), 56-65.   (Library Link)

Henriksen, K., Dayton, E., Keyes, M.A., Carayon, P., & Hughes, R. (2008). Understanding adverse events: A human factors framework. In R.G. Hughes (Ed.). Patient safety and quality: An evidence-based handbook for nurses (pp. 67-85). Agency for Healthcare Research and Quality.

Hignett, S., Jones, E.L., Miller, D., Wolf, L., Modi, C., Shahzad, M.W., Buckle, P., Banerjee, J., & Catchpole, K. (2015). Human factors and ergonomics and quality improvement science: Integrating approaches for safety in healthcare. BMJ Quality & Safety, 24, 250-254.

Hignett, S., Welsh, R., & Banerjee, J. (2021). Human factors issues working in personal protective equipment during the COVID-19 pandemic. Anaesthesia, 76, 132-143.

Jaffe, R.C., Wickersham, A., & Babula, B. (2019). Overview of healthcare quality. In D.B. Nash, M.S. Joshi, E.R. Ransom, & S.B. Ransom (Eds.). The healthcare quality book: Vision, strategy, and tools (4th ed., pp.5-47). Health Administration Press.

The Joint Commission (2015). Human factors analysis in patient safety systems. The Source, 13(4), 1-10.

Norris, B. (2009). Human factors and safe patient care. Journal of Nursing Management, 17, 203-211.

Waterson, P., & Catchpole, K. (2016). Human factors in healthcare: Welcome progress, but still scratching the surface. BMJ Quality & Safety, 2016, 480-484.  (Library link)


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