Engineering Safe Practices Affinity Group
Background
The National Action Alliance established the Engineering Safe Practices Affinity Group to make healthcare safer by design by identifying scalable opportunities for engineering safety into key healthcare practices—one of the Alliance’s five Aims. Read more about the Aims and the approach the Alliance is taking to achieve them.
Strategies to Engineer Safety into Healthcare Delivery
Although it has long been used to improve safety in other industries, human factors engineering is often underutilized in healthcare. However, safety engineering offers the opportunity to lessen reliance on individuals and build healthcare delivery systems that are safe, effective, and efficient.
The National Action Alliance for Patient and Workforce Safety identified the need to facilitate the widespread adoption of strategies that make it more difficult for people to make errors in care delivery or experience a work-related injury using human factors engineering principles. This document provides an overview of some safety engineering principles, strategies, change concepts, and examples for those seeking to make their systems safer.
- Download Strategies to Better Engineer Safety into Healthcare Delivery (PDF, 375 KB)
Strategies and Change Concepts
Rationale: Safety engineering is based on a proactive approach using both prospective and retrospective analysis tools accompanied by constant surveillance. The identification of workarounds may be a signal that a process is not functioning well. Advances in knowledge and changing expectations and priorities are inevitable. Healthcare organizations can use established methods and tools to incorporate hazard anticipation, prevention, and mitigation into routine operations.
Opportunities: Routinely assess processes for potential gaps, changes, or unidentified opportunities and redesign outdated processes. Conduct routine and ad-hoc briefings and debriefings to assess and respond to healthcare worker, patient, and family concerns and early warnings. Establish standard contingency plans for high-risk failures such as cybersecurity breaches, natural disasters, and mass casualty events. Develop processes to adapt, communicate, and continue operations during unexpected conditions, such as changes in the availability of medication, equipment, supplies, and staff.
Resources
- Center for Disease Control and Prevention (CDC) Training: Safety Culture in Healthcare Settings includes strategies to identify risks and hazards and prevent/control work-related injury.
- Workarounds and Resiliency on the Front Lines of Health Care.
- FDA Drug Shortage Database to identify and plan for potential supply gaps.*
- Institute for Healthcare Improvement Patient Safety Leadership WalkRounds.
Tools
- AHRQ's Healthcare-Associated Infections Program (contains multiple resources and toolkits).*
- Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care.*
- OSHA Safe Patient Handling Information and Implementation Guidance.
Examples
- Continuous Monitoring with Sedative and Analgesia Administration.*
- Inpatient Respiratory Arrest Associated with Sedative and Analgesic Medications: Impact of Continuous Monitoring on Patient Mortality and Severe Morbidity.*
* Indicates an AHRQ-supported tool or resource
Rationale: Organizing processes, supplies, equipment, and technology interfaces with human factors principles can reduce the risk of error and harm. Such approaches make it easier to carry out work as intended, improving efficiency and job satisfaction while reducing stress.
Opportunities: Optimize and standardize equipment interfaces, medication carts, workstations, and emergency and resuscitation supplies. Provide and periodically modify visual, auditory, and/or tactile cues for hazards. Optimize menu choices while minimizing unnecessary alerts. Use simulation to improve processes and perform leadership rounds to engage frontline staff.
Resources
- Feedback from Consumer Assessment of Healthcare Providers and Systems (CAHPS).*
- Feedback from Surveys on Patient Safety Culture (SOPS).*
- Feedback from Patient Safety Leadership WalkRounds.*
Tools
- Mapping method for complex, non-linear functions and relationships: Functional resonance analysis method (FRAM).
- Assistant Secretary for Technology and Policy (ASTP) SAFER Guides to address Electronic Health Record safety.
Examples
- Resuscitation Cart Medication Drawer Redesign.
- Shrink-wrapping paralytic medications as a visual and tactile cue.
- Displaying Patient Photos in Medical Records Reduces Errors, Improves Patient Safety.*
* Indicates an AHRQ-supported tool or resource
Rationale: Structuring the built environment to minimize physical hazards and reduce the physical burden on staff will improve workflows, promote safety, and support efficiency.
Opportunities: Design patient care spaces to facilitate patient care and minimize hazards to healthcare workers (e.g., tripping hazards). Design spaces for patients with behavioral health conditions that provide safety for patients and healthcare workers. Include safety engineering expertise for renovations and new construction.
Resources
- Transforming Hospitals: Designing for Safety and Quality.*
- Improving Healthcare Safety by Enhancing Healthcare Facility Design.*
Tools
- Safe OR Design Tool.*
- Hazard Assessment and Remediation Tool [HART] for Simulation-Based Healthcare Facility Design Testing.*
Examples
- Architect Feedback for Safer Patient Rooms.*
- Using Simulation to Support Evidence-Based Design of Safer Health Care Environments.
* Indicates an AHRQ-supported tool or resource
Rationale: Patients are vulnerable at the many intersections of care transitions, particularly the reconciliation of medications and information captured in electronic health records. Transitions may be within or between facilities and providers, a patient’s home, or other healthcare delivery settings.
Opportunities: Evaluate and improve the accuracy and effectiveness of handoff processes and use structured tools or processes for handoff communication and medication reconciliation.
Resources
- Towards a More Patient-Centered Approach to Medication Safety.*
- Mapping the Care Transition from Hospital to Skilled Nursing Facility.*
- Engineering safer care coordination from hospital to home: Lessons from the USA.
Tools
- Task analysis, including cognitive task analysis.*
- Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.*
- Evaluating the Usability of an Emergency Department After-Visit Summary: Staged Heuristic Evaluation.
- I-PASS handoff tool.
Examples
- Applying the Medications at Transitions and Clinical Handoffs Toolkit in a Rural Primary Care Clinic.*
- I-PASS for Improved Resident Handoffs.*
* Indicates an AHRQ-supported tool or resource
Rationale: Individual- and team-based continuous learning supported by iterative feedback is essential for high reliability in healthcare. There are many learning modalities, both formal and spontaneous. Psychological safety and opportunities for reflection both support learning.
Opportunities: Implement purposeful briefings or huddles at tiered levels (e.g., unit, team, shift) and incorporate debriefings after procedures/events (“hot”) and as regularly scheduled activities (“cold”) to address routine processes as well as instances of exceptionally poor or good outcomes. This Safety-II approach assumes that everyday performance variability provides the adaptations needed to respond to varying conditions and that both success and failure offer learning opportunities. Incorporate training opportunities for team members to develop debriefing facilitation skills. Establish informal and formal reporting systems to identify successes as well as harmful events, errors, near-miss events, and unsafe conditions with the option of anonymous reporting.
Resources
Tools
- Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events.*
- Calibrate Dx: A Resource to Improve Diagnostic Decisions.*
- Using Root Cause Analysis to Improve Quality and Performance.*
- TeamSTEPPS® (Strategies and Tools to Enhance Performance and Patient Safety).*
Examples
- Taking Morbidity and Mortality Conferences to a Next Level: The Resilience Engineering Concept.
- Conduct debriefings (or after-action reviews) after clinical events to improve future performance: Institute for Healthcare Improvement Safety Briefings Tool.
- Caregiver Innovations to Reduce Harm in Neonatal Intensive Care.*
* Indicates an AHRQ-supported tool or resource
AHRQ wishes to acknowledge and thank the following people and organizations for sharing their expertise on the Affinity Group:
| Contributor | Organization |
|---|---|
| Pascale Carayon, Ph.D., Professor Emerita, Department of Industrial & Systems Engineering; Founding Director, Wisconsin Institute for Healthcare Systems Engineering | University of Wisconsin–Madison |
| Chris DeRienzo, M.D., M.P.P., Senior Vice President, Chief Physician Executive | American Hospital Association |
| Rollin J. “Terry” Fairbanks, M.D., M.S., Senior Vice President and Chief Quality & Safety Officer | MedStar Health |
| Lillee Gelinas, D.N.P., R.N., CPPS, FAAN, Assistant Professor, Medical Education & Health Systems Science; Patient Safety Director | Texas College of Osteopathic Medicine, The University of North Texas Health Science Center |
| Ayse Gurses, Ph.D., M.S., M.P.H., Director of Armstrong Institute Center for Health Care Human Factors and Professor of Anesthesiology & Critical Care Medicine | Johns Hopkins University, Malone Center for Engineering in Healthcare |
| Anjali Joseph, Ph.D., Endowed Chair in Architecture & Health Design | Clemson University and Spartanburg Regional Health System |
| Scott Lucas, Ph.D., PE, Vice President of Device Safety | ECRI |
| Elizabeth Mort, M.D., M.P.H., Chief Medical Officer | The Joint Commission |
| Christine Sinsky, M.D., Vice President for Professional Satisfaction | American Medical Association |
| Rupa S. Valdez, Ph.D., M.S., Associate Professor of Public Health Sciences & Engineering Systems and Environment, Department of Public Health Sciences & Department of Systems and Information Engineering | University of Virginia |
| Kayla Waldron, Pharm.D., M.S., BCPS, Director of Medication Use and Quality Improvement | American Society of Health-System Pharmacists |
Federal Partners
| Contributor | Organization |
|---|---|
| Martha Betz, Ph.D., Associate Director of Post Market Programs, Center for Devices and Radiological Health | Food and Drug Administration |
| Lauri Hicks, D.O., FACP, Chief, Medical Product Safety Branch, Division of Healthcare Quality & Promotion | Centers for Disease Control and Prevention |
| David Hunt, M.D., Medical Director, Patient Safety | Assistant Secretary for Technology Policy / Office of the National Coordinator for Health Information Technology |
National Action Alliance Facilitators
| Contributor | Organization |
|---|---|
| Ellen S. Deutsch, M.D., M.S., FACS, FAAP, FSSH, Medical Officer, Division of General Patient Safety, Center for Quality Improvement and Patient Safety | Agency for Healthcare Research and Quality |
| Fran Griffin, M.P.A., RRT, Consultant | Ripple Effect |
| Jennifer Trallo Schreiber, M.S.N., M.B.A., R.N., CPPS, CPHQ, Principal Program Analyst | Ripple Effect |
