Table 1

Actions based on human factors engineering principles

Stronger actions

  • Architectural/physical plant changes

  • New devices with usability testing before purchasing

  • Engineering control of interlock (forcing functions)

  • Simplify the process and remove unnecessary steps

  • Standardise on equipment on process or care maps

  • Tangible involvement and action by leadership in support of patient safety

Intermediate actions

  • Redundancy

  • Increase in staffing/decrease in workload

  • Software enhancements/modifications

  • Eliminate/reduce distractions (sterile medical environment)

  • Checklist/cognitive aid

  • Eliminate look and sound-alike

  • Read back

  • Enhanced documentation/communication

Weaker actions

  • Double checks

  • Warnings and labels

  • New procedure/memorandum/policy

  • Training

  • Additional study/analysis