Pa Patient Saf Advis 2016 Jun;13(2):79.
That Pesky Human Factor

Ellen S Deutsch, MD, MS, FACS, FAAP, CPPS
Editor, Pennsylvania Patient Safety Advisory
Medical Director, Pennsylvania Patient Safety Authority


When I hear the term “human factor” mentioned in a root-cause analysis or in the discussion of an Incident or Serious Event, I cringe and wait, wondering what the speaker means by that term. I have two concerns, and I look forward to the day when both are unfounded.

My first concern is that mention of “the human factor” is sometimes a code for identifying “what the human did wrong,” intended to reference the perception that human fallibility is inevitable. It’s true that humans make mistakes. Despite good intentions, our knowledge, judgment, and skills can be imperfect. We know that “to err is human”1 and are further told that “to err is human – and let’s not forget it.”2 

Fortunately, humans have strengths as well as weaknesses. Humans invent. Humans create and develop healthcare advances and solutions. Humans solve problems. Humans learn and improve themselves, their teams, and the complex systems they work within. Humans offer empathy and compassion. Healthcare providers work to provide ever-improving healthcare. In fact, “people working in health care are among the most educated and dedicated work force in any industry.”1 The Pennsylvania Patient Safety Authority celebrates these attributes in our annual “I Am Patient Safety” campaign. Every March, we provide recognition for individuals and groups within Pennsylvania’s healthcare facilities who have demonstrated exceptional activities in support of patient safety, at the Board of Directors meeting and in the Pennsylvania Patient Safety Advisory. We can adopt the refreshing perspective that “to better is human.”3

My second concern is that too few people are aware that Human Factors (HF) is a field of science that can provide insights and techniques to help us better understand our capabilities and improve our relationships with the complex systems that are integral to providing safe healthcare. HF is “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system.”4 HF professionals apply “theory, principles, data, and methods to design in order to optimize human well-being and overall system performance.”4 Harnessing HF principles can help us augment human capabilities that are weak, such as providing convenient, timely decision support information rather than relying on memorizing long lists of medication dosages. Conversely, employing HF principles can help us leverage human capabilities that are unique and powerful, such as the ability to synthesize complex information from a patient’s history and physical examination to develop an accurate diagnosis.

The range of HF applications in healthcare is quite broad, including both physical and cognitive capabilities and processes. The Human Factors and Ergonomics Society’s website lists the varied interests of HF experts and provides insight into HF applications that can be useful in healthcare.5 HF experts may address:

  • The design of a tool or piece of equipment, so that information about correct use is provided within the design of the equipment and the risk of incorrect use is minimized; using ergonomic data and principles to improve the safety, productivity, and quality of work.5
  • The design and impact of computer systems and other technologies, including hardware, software, applications, documentation, work activities, and work environment.5 HF recommendations can improve the usability of electronic health records (EHRs), and contribute to improving patient safety by providing guidance about preparing and conveying information so that it can be used by human beings efficiently and effectively.6,7
  • Abstract concepts, such as situational awareness; teamwork; the effects of stress, fatigue, interruptions, and workload on performance; and human cognition and decision making, alone or in conjunction with other individuals or intelligent systems.5,8-10

While it is important for individual healthcare providers and healthcare teams to optimize their own knowledge and skills, their capabilities can be enhanced or constrained by the systems they interact with and work within. Diverse tools, equipment, technologies, protocols and care delivery processes, and systems are indivisibly integrated into the application of knowledge and skill in healthcare. Healthcare organizations are increasingly integrating HF expertise in patient care and research activities. Applying sound HF principles can help optimize the relationships between healthcare providers and healthcare delivery tools, technologies, and systems, for the benefit of our patients. I look forward to the day when widespread knowledge of HF principles allows us to support, utilize, and celebrate human capabilities.


  1. Institute of Medicine Committee on Quality of Health Care in America. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington (DC): National Academy Press; 1999 Nov 1. 223 p. 
  2. Croskerry P. To err is human--and let’s not forget it. CMAJ 2010 Mar 23;182(5):524. Also available: PMID: 20231338.
  3. MedStar Health National Center for Human Factors in Healthcare [website]. Washington (DC): MedStar Health; [accessed 2014 Nov 02]. Available:
  4. What is ergonomics? Definition and domains of ergonomics [online]. International Ergonomics Association (IEA); 2016 [accessed 2016 Mar 27]. Available:
  5. Descriptions of all technical groups [online]. Santa Monica (CA): Human Factors and Ergonomics Society (HFES); [accessed 2016 Mar 27]. Available:
  6. Armijo D, McDonnell C, Werner K. Electronic health record usability: Interface design considerations. AHRQ Publication No. 09(10)-0091-2-EF. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2009 Oct. 21 p. Also available:
  7. Lowry SZ, Quinn MT, Ramaiah M, et al. A human factors guide to enhance EHR usability of critical user interactions when supporting pediatric patient care. Gaithersburg (MD): National Insitute of Standards and Technology (NIST); 2012 Jun. 44 p. Also available:
  8. IOM (Institute of Medicine). Resident duty hours: enhancing sleep, supervision, and safety. Washington (DC): The National Academies Press; 2009. 400 p. Also available:
  9. Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med J 2014 Mar;90(1061):149-54. Also available: PMID: 24398594.
  10. Salas E, Cooke NJ, Rosen MA. On teams, teamwork, and team performance: discoveries and developments. Hum Factors 2008 Jun;50(3):540-7. PMID: 18689065.

Supplemental Material 

Selected Resources for Additional Information

Carayon P, Wood KE. Patient Safety: the role of human factors and systems engineering. Stud Health Technol Inform 2010;153:2346. [online; accessed 2016 May 18]

Topic 2: What is human factors and why is it important to patient safety? [online; accessed 2016 May 18].


The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

Current and previous issues are available online at

©2019 Pennsylvania Patient Safety Authority