Editor: John W. Gosbee

Contributing Editor: Laura Lin Gosbee

Publisher: Joint Commission Resources

Publication Date: 2005

ISBN: 0-86688-912-4

Pages: 144

Price: $80, list price; $70, AAMI member price

Human factors engineering (HFE) has emerged as an important topic for clinical engineers, biomedical equipment technicians, and other healthcare professionals. HFE is related not only to the design features of medical devices, but also to the designs and processes of complete systems that include medical devices, people (patients and staff), the environment (physical and organizational), and the many interactions among these elements.

This book is written at an introductory level and is intended to provide the reader with an overview of HFE in healthcare. It also describes how the use of HFE theory can reduce the likelihood and consequences of human error and improve patient safety. And it is intended to whet your curiosity and to lead you deeper into the resources provided in the book’s Appendix.

The editor, John Gosbee, MD, MS, is a human factors engineering and healthcare specialist at the VA National Center for Patient Safety. The contributing editor, Laura Lin Gosbee, MASc, is a human factors engineering and healthcare consultant with Red Forest Consulting.

The book is divided into two sections addressing theory and practice. Part I is a primer on human factors engineering. Part II, which represents nearly two-thirds of the book, consists of case studies by various authors. These case studies were originally articles published from April 2004 through December 2004 in the Joint Commission Journal on Quality and Safety (now renamed the Joint Commission Journal on Quality and Patient Safety).

Audience: This guideline is intended for all types of healthcare professionals including physicians, nurses, pharmacists, clinical engineers, biomedical equipment technicians, risk managers, and patient safety coordinators. All will find themselves serving as members of root cause analysis (RCA) teams, patient safety task forces, medical equipment selection committees, and other groups whose success requires a working knowledge of human factors engineering and an appreciation for the role of human error in healthcare delivery.

Features: Don’t skip over the foreword! It is written by clinical engineer Jeffrey B. Cooper, PhD, of Partners Healthcare System and the Harvard Medical School. Cooper’s groundbreaking studies on human error in anesthesia systems pioneered many of the basic methods in use today. His arguments for studying human factors engineering are fundamental and convincing.

Another feature of the book is a chapter on theory and general principles. Human factors engineering and human error theory are opposite sides of the same coin. Human factors engineering relates to the designs of systems and components of systems that a human is intended to use. Human error theory is related to human capabilities such as working and long-term memory, attention spans, and our ability to focus on one activity at a time. When human factors designs match our human capabilities and limits, the system has the best design. Chapter 1 explains the fundamental interactions of human factors engineering and human error theory.

It is possible to identify a bad human factors design feature. It may be the result of a large number of errors being associated with one system or the close examination of a system following an accident. However you identify it, improving the system by removing this factor is not always a simple task. Chapter 2 describes some of the methods and tools that you can use to improve systems.

The resources listed by the editors are both varied and useful to readers at several interest levels. If you are a beginner, read Donald Norman’s Design of Everyday Things. If advanced, jump to Wickens’ Introduction to Human Factors Engineering or AAMI’s Human Factors Design Process for Medical Devices. Many listed resources are available for free on the Internet.

The featured case studies are current and have particular interest. They are accidents or incidents experienced and analyzed by authors of various backgrounds and from different hospitals. They not only demonstrate that understanding human factors engineering can prove useful in improving healthcare systems, they also illustrate the application of the theory, principles, and practices found in the early chapters of this book.

Throughout the case studies there are numerous references to activities that represent important opportunities for clinical engineers and biomedical equipment technicians. One such activity is involvement in medical equipment planning and acquisition. Knowledge of human factors engineering will make our participation more effective and more likely to be invited. However, it is curious that the book does not mention ECRI and its Health Devices journal among the resources for medical equipment planning. Other key opportunities include participation in incident investigation teams, which requires knowledge of root cause analysis and identification of latent errors, or through review of “no problem found” work orders.

Assessment: This manual is not intended to make you an expert in human factors engineering. It is intended to stimulate your interest in the topic, introduce the basics of human factors engineering and human error theory, and provide reference sources to pursue the subject further. There are a few typos but it is generally well written and easy to understand. It is a good primer and reference for your bookshelf, for assigned reading to your staff, and for an introductory short-course in human factors engineering.