2. Make sure patients understand their treatment – You may think all patient safety responsibilities fall to the healthcare provider, but making sure that patients are informed about their own care is also vital to preventing errors. This doesn’t mean patients need to have the same knowledge of their situation as a healthcare professional—but a high-level understanding of the treatment and the risks they face can go a long way.
Contents
What are the factors affecting patient safety in the hospital?
Discussion – The survey result showed that the overall patient safety culture within the facility was 37% (95% CI: 35.3, 38.8). This result is slightly lower than studies conducted in different regions of the country, ranging from 44% in both studies conducted in Addis Ababa and Bale to 49.2% in a study conducted in East Wollega Zone.11, 12, 21–23 This result is also lower as compared to studies conducted in Tunisia (40.73%), Iran (44.82%) and Brazil (51.06%), India (58%), and Nigeria (66.86%).24–28 The difference is justifiable given that, patient safety culture is influenced by several factors that vary among hospitals.
Hospitals with strong safety cultures prioritize patient safety, have strong leadership commitment, provide staff education and training, encourage open communication, involve patients in their care, have established reporting and learning systems, and ensure adequate staffing levels and manageable workloads.18 In this study of the 12 dimensions, Teamwork within the hospital units (75.3%) and Organizational learning – Continuous improvement (62.2%) was with the highest average positive response rate.
The finding is comparable with the study conducted in Bale Zone and Gondar, Ethiopia, as well as a systematic review conducted in European hospitals.12, 14, 15 This result shows that ten out of the 12 patient safety dimensions are areas for improvement (scored less than 50%), and the situation in the hospital is alarming.
The lowest positive response rate was recorded in “Frequency of event reporting” scoring 20.7% average positive response rate and events were reported by 8.9% of the study participants. The qualitative study supported this result, and the root causes for poor event reporting practice are briefly discussed as the absence of an event reporting system within the organization and poor documentation practice by health professionals.
Accordingly, findings in a study revealed that the lack of a standardized reporting system is a major impeding factor for poor event reporting culture.29 The shortage of staffs and poor staff development program of the study facility might also play a vital role on the poor event reporting practice.
A study findings showed that poor adverse event reporting was associated with inadequate staffing and lack of training.30 Furthermore, a lack of event reporting mechanisms and poor documentation can have a significant impact on patient safety as it may lead to medical errors going unnoticed, maximize the inability to learn from mistakes, and normalization of unsafe practices which can result in harm to patients.31 Health-care workers’ perception plays a crucial role in patient outcomes and safety culture within health-care settings.32 The current analysis highlighted poor attitude as a roadblock to enhancing patient safety culture.
Similarly, another study conducted in South Africa found that a negative attitude among health professionals was responsible for the organization’s poor patient safety culture.33 This unfavourable attitude can lead to poor communication, lack of teamwork, and a decreased focus on patient-centered care, thus compromising the overall patient safety and quality of care provided to patients.34 Poor cooperation of clients and their families affects patient safety culture in various ways, ranging from reduced adherence to treatment, miscommunication, and mistrust, to inadequate monitoring and follow-up.35–37 Similarly, in the current study, poor cooperation by patients and their families was believed to be one of the factors affecting patient safety culture within the study facilities.
- According to this study, the lack of proper staff training and ongoing education has a detrimental impact on patient safety culture.
- The finding is consistent with a review of qualitative research that concluded a lack of staff training and continuing education was to blame for hospitals’ poor patient safety culture.38 It is evident that staff training and continuous education play a crucial role in fostering a patient safety culture within health-care organizations.
Hence, the absence of adequate staff training and continuous education negatively affects patient safety culture, leading to an increased risk of errors, adverse events, and patient harm.39 Patients’ lack of understanding about the importance of their role in their own care as a result of an inadequate client education program contributes significantly to poor patient safety.
Similarly, research conducted in Gonder, Ethiopia, discovered that the lack of systematic client education was also to blame for the organization’s poor patient safety culture.22 Patients who are not educated about their health conditions, treatment options, or how to properly take medication and safety precautions may be more likely to experience adverse events, such as medication errors or hospital-acquired infections.
Lack of facility level Standard Operation Procedures (SOP) and policies was pointed out as the main reason for inconsistency in patient care practices. Another similar study raised the same argument as lack of SOP and guideline was responsible for poor patient safety.29 The absence of guidelines can lead to inconsistencies in care, decreased efficiency, miscommunication, and failure to adequately learn from errors.
Participants in this study pointed out shortage of personal protective equipment (PPE) was putting patient safety at risk. The shortage of PPE may contribute to increasing stress levels in health-care workers due to feelings of vulnerability, fear of infecting patients and family members, and ethical dilemmas concerning rationing of essential resources.
Consequently, overwhelmed and anxious health-care workers may be less equipped to provide safe, quality care.40 Staff shortage and high work load affect patient safety culture in several ways. This study also pointed out those challenges for improving patient safety culture were high work load and staff shortage.
What is human factors and why is it important to patient safety?
Human factors are those things that affect an individual’s performance. A human factors approach is key to safer healthcare. It will become part of the core curricula of all health professionals. Training needs to be co-ordinated along interprofessional lines.
What are the five 5 other factors that could affect health?
Frequently Asked Questions Health equity can be defined in several ways. One commonly used definition of health equity is when all people have “the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance'”.1 The U.S.
Department of Health and Human Services defines health equity as attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.2 Achieving health equity, eliminating disparities, and improving the health of all groups is an overarching goal for Healthy People 2020 and a top priority for the Centers for Disease Control and Prevention (CDC).3 Health is influenced by many factors, which may generally be organized into five broad categories known as determinants of health: genetics, behavior, environmental and physical influences, medical care and social factors.
These five categories are interconnected. The fifth category (social determinants of health) encompasses economic and social conditions that influence the health of people and communities.4 These conditions are shaped by socioeconomic position, which is the amount of money, power, and resources that people have, all of which are influenced by socioeconomic and political factors (e.g., policies, culture, and societal values).5,6 An individual’s socioeconomic position can be shaped by various factors such as their education, occupation, or income.
- How a person develops during the first few years of life (early childhood development)
- How much education a person obtains and the quality of that education
- Being able to get and keep a job
- What kind of work a person does
- Having food or being able to get food (food security)
- Having access to health services and the quality of those services
- Living conditions such as housing status, public safety, clean water and pollution
- How much money a person earns (individual income and household income)
- Social norms and attitudes (discrimination, racism and distrust of government)
- Residential segregation (physical separation of races/ethnicities into different neighborhoods)
- Social support
- Language and literacy
- Incarceration
- Culture (general customs and beliefs of a particular group of people)
- Access to mass media and emerging technologies (cell phones, internet, and social media)
All of these factors are influenced by social circumstances. Of course, many of the factors in this list are also influenced by the other four determinants of health. Addressing social determinants of health is a primary approach to achieving health equity.
Health equity is “when everyone has the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance'”.7 Health equity has also been defined as “the absence of systematic disparities in health between and within social groups that have different levels of underlying social advantages or disadvantages—that is, different positions in a social hierarchy”.8 Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities.
The Centers for Disease Control and Prevention (CDC) is committed to achieving improvements in people’s lives by reducing health inequities. Health organizations, institutions, and education programs are encouraged to look beyond behavioral factors and address underlying factors related to social determinants of health.
A growing body of research highlights the importance of upstream factors that influence health and the need for policy interventions to address those factors—in addition to clinical approaches and interventions aimed at modifying behavior.9 The Centers for Disease Control and Prevention (CDC) is committed to achieving improvements in people’s lives by reducing health inequities.
Health organizations, institutions, and education programs are encouraged to look beyond behavioral factors and address underlying factors related to social determinants of health. The created the to address social determinants of health.4 The Commission uses the following three principles to guide its work in eliminating health inequities for local communities and nations and throughout the world: Figure 1. World Health Organization’s Social Determinants of Health Conceptual Framework 4
- Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and age.
- Tackle the inequitable distribution of power, money, and resources—the structural drivers of those conditions of daily life—globally, nationally, and locally.
- Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.4
The commission created the conceptual framework below that describes relationships among individual and structural variables. The framework represents relationships among variables that are based on scientific studies or substantial evidence. The framework provides a point from which researchers can take action, such as creating targeted interventions, on social determinants of health.
- More information is available from a variety of sources, including the following publications and web sites.
- Websites
- Publications
- . Editors Erik Blas and Anand Sivasankara Kurup.2010, World Health Organization: Geneva.
- Commission on Social Determinants of Health (CSDH),,2008, World Health Organization: Geneva.
- Hillemeier, M., Lynch, J., Harper, S., Casper, M.,,2004, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services: Atlanta.
- Brennan Ramirez LK, Baker EA, Metzler M., Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.
- Hofrichter, R., Bhatia, R. (Eds.) Tackling Health Inequities through Public Health Practice: Theory to Action.2010, Oxford University Press.
- Raphael, D., ed. Social determinants of health: Canadian perspectives,2004, Canadian Scholars’ Press Toronto.
- Marmot, M.G. and R.G. Wilkinson, Social determinants of health,2nd ed.2006, Oxford ; New York: Oxford University Press. x, 366 p.
You can e-mail the Office of Health Equity at,
- Braveman, P.A., Monitoring equity in health and healthcare: a conceptual framework, Journal of health, population, and nutrition, 2003.21(3): p.181.
- U.S. Department of Health and Human Services,,2018.
- CDC, ; ODPHP,,
- Commission on Social Determinants of Health (CSDH), Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health,2008, World Health Organization: Geneva.
- U.S. Department of Health and Human Services., Social Determinants of Health.
- Commission on Social Determinants of Health (CSDH). A Conceptual Framework for Action on the Social Determinants of Health. Discussion Paper for the Commission on Social Determinants of Health DRAFT.2007, World Health Organization: Geneva.
- Brennan Ramirez LK, B.E., Metzler M., Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, Centers for Disease Control and Prevention, Editor.2008, Department of Health and Human Services: Atlanta, GA.
- Braveman, P. and S. Gruskin, Defining equity in health. Journal of Epidemiology and Community Health, 2003.57(4): p.254-258.
- Health Policy Brief: “The Relative Contribution of Multiple Determinants to Health Outcomes,” Health Affairs, August 21, 2014.
What are the 5 human factors?
Five Human Factors Ideal innovation phases for this method:
- Innovation Phase
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
The Five Human Factors method is about studying the physical, cognitive, social, cultural and emotional factors that make up a complete customer experience.The Five Human Factors support customer observations in the field during the observation phase of an innovation project.
- If we grasp the five factors in a structured way and think them through in detail, we gain a target-oriented, deep understanding of the customer experience.
- This holistic observation increases the likelihood of finding unresolved problems and unmet customer needs that demand an innovative solution.
- The method breaks down a customer experience into its individual components in order to better understand them.
Then the entire customer experience is reassembled in order to clearly understand the cause-effect relationships that lie hidden within it.
- Effective for disruptive innovations
- Effective for highly complex challenges
- Effective for medium complex challenges
- Effective for new business models
- Effective for product innovations
- Effective for radical innovations
- Effective for service innovations
P3 Observe (people – environment – product use)
: Five Human Factors
What are the 7 human factors?
In summary, some of the common human factors that can increase risk include: mental workload distractions the physical environment physical demands device/product design teamwork process design.
What 7 factors impact on your work and patient safety?
2.1 Human Errors and Organizational Accidents – The 1999 report by the IOM on “To Err is Human: Building a Safer Health System” highlighted the role of human errors in patient safety ( Kohn, et al., 1999 ). There is a rich literature on human error and its role in accidents.
- The human error literature has been very much inspired by the work of Rasmussen ( Rasmussen, 1990 ; Rasmussen, Pejtersen, & Goodstein, 1994 ) and Reason (1997), which distinguishes between latent and active failures.
- Latent conditions are “the inevitable “resident pathogens” within the system” that arise from decisions made by managers, engineers, designers and others ( Reason, 2000, p.769).
Active failures are actions and behaviors that are directly involved in an accident: (1) action slips or lapses (e.g., picking up the wrong medication), (2) mistakes (e.g., because of lack of medication knowledge, selecting the wrong medication for the patient), and (3) violations or work-arounds (e.g., not checking patient identification before medication administration).
In the context of health care and patient safety, the distinction is made between the “sharp” end (i.e. work of practitioners and other people who are in direct contact with patient) and the “blunt” end (i.e. work by healthcare management and other organizational staff) (R.I. Cook, Woods, & Miller, 1998 ), which is roughly similar to the distinction between active failures and latent conditions.
Vincent and colleagues (2000 ; 1998) have proposed an organizational accident model based on the research by Reason (1990, 1997), According to this model, accidents or adverse events happen as a consequence of latent failures (i.e. management decision, organizational processes) that create conditions of work (i.e.
- Workload, supervision, communication, equipment, knowledge/skill), which in turn produce active failures.
- Barriers or defenses may prevent the active failures to turn into adverse events.
- This model defines 7 categories of system factors that can influence clinical practice and may result in patient safety problems: (1) institutional context, (2) organizational and management factors, (3) work environment, (4) team factors, (5) individual (staff) factors, (6) task factors, and (7) patient characteristics.
Another application of Rasmussen’s conceptualization of human errors and organizational accidents focuses on the temporal process by which accidents may occur. Cook and Rasmussen (2005) describe how safety may be compromised when healthcare systems operate at almost maximum capacity.
Under such circumstances operations become to migrate towards the marginal boundary of safety, therefore putting the system at greater risk for accidents. This migration is influenced by management pressure towards efficiency and the gradient towards least effort, which result from the need to operate at maximum capacity.
An extension of the human error and organizational accidents approach is illustrated by the work done by the World Alliance for Patient Safety to develop an international classification and a conceptual framework for patient safety. The International Classification for Patient Safety of the World Health Organization’s World Alliance for Patient Safety is a major effort at standardizing the terminology used in patient safety ( Runciman, et al., 2009 ; The World Alliance For Patient Safety Drafting Group, et al., 2009 ).
- The conceptual framework for the international classification can be found in Figure 1 ( The World Alliance For Patient Safety Drafting Group, et al., 2009 ).
- Patient safety incidents are at the core of the conceptual framework; incidents can be categorized into healthcare-associated infection, medication and blood/blood products, for instance ( Runciman, et al., 2009 ).
The conceptual framework shows that contributing factors or hazards can lead to incidents; incidents can be detected, mitigated (i.e. preventing or moderating patient harm), or ameliorated (i.e. actions occurring after the incident to improve or compensate for harm). These different models of human errors and organizational accidents are important in highlighting (1) different types of errors and failures (e.g., active errors versus latent failures; sharp end versus blunt end), (2) the key role of latent factors (e.g., management and organizational issues) in patient safety ( Rasmussen, et al., 1994 ; Reason, 1997 ), (3) error recovery mechanisms ( Runciman, et al., 2009 ; The World Alliance For Patient Safety Drafting Group, et al., 2009 ), and (4) temporal deterioration over time that can lead to accidents (R.
What are two external factors that can affect patient safety?
The Physical Environment: An Often Unconsidered Patient Safety Tool | PSNet Now that health care reimbursement is firmly linked to a reduction in hospital-acquired conditions through the enactment of the Affordable Care Act, the entire health care industry has additional incentive to address our patient safety problems aggressively.
- Although there has been recent progress in patient safety (), perhaps one reason for the troubling gaps is that all of the variables that contribute to safe and quality care have not been examined together.
- One often-neglected variable is the physical environment, which shapes every patient experience and all health care delivery, including those episodes of care that result in patient harm.
Other high-risk industries have studied how environmental features can engender human responses that improve safety-related outcomes.() Understanding how environmental variables contribute to adverse events in health care represents the focus of a growing body of architects, researchers, and clinicians.() A systems approach allows us to evaluate error or adverse events in the context of organizational vulnerabilities.
As seen in the, environmental latent conditions undermine system defenses, setting the stage for active failures or establishing error-provoking conditions.() For example, multiple occupancy patient rooms that are more difficult to clean and have fewer easily accessible handwashing opportunities (bathrooms, sinks, alcohol rubs) may result in increased transmission of health care–associated infections (HAIs) through surface contact.() Evidence-based Design Evidence-based design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.() The Center for Health Design, a 501(c)(3) nonprofit organization, is committed to assisting health care organizations achieve this goal through their Pebble Project program (), a research initiative that engages health care organizations during their facility design and construction projects.
Team members use research findings to inform decision-making and then conduct additional research to evaluate the effectiveness of implemented design strategies. Below, we discuss some of the key findings from the Pebble partners as they relate to patient safety and summarize the research linking facility design hazards and latent conditions to patient safety outcomes.
- Patient Safety Trifecta and Environmental Tools
- We have noted three main patient safety areas markedly influenced by the environment: HAIs, medication safety, and falls.
- Health Care–Associated Infections
Because HAIs are transmitted through air, water, and contact with contaminated surfaces, the physical environment plays a key role in preventing the spread of infections in health care settings.() Evidence shows that single-bed patient rooms with high-efficiency particulate air filters and with negative or positive pressure ventilation are most effective in preventing airborne pathogens.() Single-bed patient rooms are also easier to clean and have fewer surfaces that act as reservoirs for pathogens.
Additionally, higher sink-to-bed ratios in single-patient rooms is associated with better handwashing compliance—a key factor associated with the spread of HAI.() Bronson Methodist Hospital in Kalamazoo, Michigan found that HAI rates among all patient care units declined by 11% (0.89 to 0.80 infections per 1000 patient days) when they moved from an older hospital with mostly semiprivate rooms and shared bathrooms to a new hospital with all private rooms with bathrooms.
Moreover, among the six patient care units that changed from semiprivate to private room design, the infection rate declined by 45%.() In addition, easy access to alcohol-based rub dispensers in patient rooms has been linked to improved handwashing compliance.() One study found that alcohol-rub dispensers located at the foot of the patient bed were better used than those by the sink.() Medication Safety A growing body of research suggests that medication safety is markedly influenced by the physical environmental conditions in areas where medication-related activities occur.
These conditions include light levels, sound and noise, workspace design to mitigate interruptions and distractions, and workspace organization.() Performance on visual tasks such as dispensing medications improved in an outpatient pharmacy at higher illumination levels.() Poor acoustic environments with hard sound reflecting surfaces may contribute to low speech intelligibility, which may also contribute to errors.() Acuity-adaptable rooms that enable patients to stay in the same room as their acuity level changes reduce the need for transfers and associated breakdowns in communication that potentially result in error.
Hendrich and colleagues () found that after a move to an innovative acuity-adaptable Cardiac Comprehensive Critical Care unit at Clarian Methodist Hospital, patient transfers decreased by 90% and medication errors by 70%. Patient Falls It is widely accepted that the physical environment—including environmental features, such as the placement of doorways, handrails and toilets, flooring type, and the design and location of hazards like furniture—can contribute to patient falls and associated injuries.
- Because most studies in this area have involved multifaceted-interventions to reduce falls (), the independent impact of any single design strategy remains to be evaluated.
- Hendrich and colleagues () found that most falls occurred when patients attempted to get out of bed unassisted or unobserved.
- In their study, when patients moved from a centralized unit with semiprivate rooms to decentralized units with single-patient rooms that included a family zone, the number of falls was reduced by two-thirds.
Creating space that can accommodate family members (who can help or call for aid) in the patient’s room, along with better visibility from the nurses’ station represent promising design interventions. Safe Facility Design Checklist Over the course of a health care career, all practitioners will be exposed to health care environmental changes that can range from routine maintenance and repair activities to a facility replacement project.
- Have safety goals been identified as a project driver?
- Does the architectural firm have patient safety design expertise?
- Does the design support the desired safety concepts of operation from all perspectives: patients, family and visitors, staff, material movement, equipment, and technology use?
- Are specific resources needed, such as mock-up rooms or virtual tools, to integrate safety culture, process, and environmental feature changes?
- For routine maintenance and repair activities, are there product choices that better support patient safety (e.g., replacing worn ceiling tiles with high-sound absorbing tiles to reduce noise, an error-provoking condition)?
- Have the baseline, preoccupancy safety outcome measures been captured for those variables expected to be impacted by the design?
- Have the postoccupancy evaluations of safety outcomes been included as part of the organization’s performance improvement program or in a more formal research study?
The expected growth of health care construction investments over the next 5 years presents a singular opportunity to further our understanding about how the physical environment contributes to safer and more reliable care. Each patient safety improvement plan should consider environmental solutions.
- Anjali Joseph, PhD Director of ResearchThe Center for Health Design
- Eileen B. Malone, RN, MSN, MS Member, Research CoalitionThe Center for Health Design
- References
Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood).2010;29:165-173. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748. Ulrich RS, Zimring CM, Zhu X, et al.
- A review of the research literature on evidence-based healthcare design.
- Health Environ Res Des.2008;1:61-125.
- Joseph A, Taylor E.
- Designing for patient safety: developing a patient safety risk assessment.
- In: Facility Guidelines Institute, ed.2010 Guidelines for Design and Construction of Health Care Facilities Workshops.
Chicago, IL: American Society for Healthcare Engineering; 2010. ISBN: 9780872588592. Joseph A, Rashid M. The architecture of safety: hospital design. Curr Opin Crit Care.2007;13:714-719. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
- Infect Control Hosp Epidemiol.2010;31:283-294. Joseph A.
- The impact of the environment on infections in healthcare facilities.
- Concord, CA: The Center for Health Design; 2006.
- Evidence-Based Design Accreditation and Certification (EDAC).
- Concord, CA: The Center for Health Design.
- Bartley JM, Olmsted RN, Haas J.
Current views of health care design and construction: practical implications for safer, cleaner environments. Am J Infect Control.2010;38(5 suppl 1):S1-S12. Kaplan LM, McGuckin M. Increasing handwashing compliance with more accessible sinks. Infect Control.1986;7:408-410.
Van Enk RA. Modern hospital design for infection control. Healthcare Design. September 1, 2006. Somner JEA, Scott KM, Gibb A. What is the optimum location of alcohol-based hand cleanser? Infect Control Hosp Epidemiol.2007;28:108-109. USP-NF. General chapter physical environments that promote safe medication use.
Pharmacopeial Forum.2010;34:1549-1558. Buchanan TL, Barker KN, Gibson JT, Jiang BC, Pearson RE. Illumination and errors in dispensing. Am J Hosp Pharm.1991;48:2137-2145. Joseph A, Ulrich R. Sound control for improved outcomes in healthcare settings. Concord, CA: The Center for Health Design; 2007.
Hendrich A, Fay J, Sorrells A. Effects of acuity-adaptable rooms on flow of patients and delivery of care. Am J Crit Care.2004;13:35-45. Gulwadi GB, Calkins MP. The impact of healthcare environmental design on patient falls. Concord, CA: The Center for Health Design; 2008. Choi YS, Lawler E, Boenecke CA, Ponatoski ER, Zimring CM.
Developing a multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: a systematic review. J Adv Nurs.2011;67:2501-2524. Malone EB, Dellinger BA. Furniture design features and healthcare outcomes. Concord, CA: The Center for Health Design; 2011.
- Hendrich A.
- Case study: the impact of acuity adaptable rooms on future designs, bottlenecks and hospital capacity.
- Paper presented at: Impact Conference on Optimizing the Physical Space for Improved Outcomes, Satisfaction and the Bottom Line; 2003; Atlanta, GA.
- FMI’s Construction Outlook: 1st Quarter 2012 Report.
Raleigh, NC: FMI Corporation. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ.1998;316:1154-1157. Reason J. Human error: models and management. BMJ.2000;320:768-770.
- Figure
- Conceptual model based on Vincent () and Reason’s () work showing the role of the physical environment as a latent condition or barrier/safeguard for patient safety.()
Click to enlarge.1066> This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. Patient Safety Innovations Patient Safety Innovations Patient Safety Innovations Patient Safety Innovations Patient Safety Innovations : The Physical Environment: An Often Unconsidered Patient Safety Tool | PSNet
