Using a Human Factors and Systems Engineering Framework to Build Safer Patient Care Processes

Pascale Carayon, Ph.D.


“I’m grateful that AHRQ was a leader in recognizing the value of human factors and systems engineering as a method to understand and reduce patient safety risks. I’m hopeful that my research will make patients’ journey through the health system a safer one.”


Human factors and systems engineering, or the science of how to design and manage complex human-centered systems, has long been used in high-risk industries such as manufacturing and aviation to promote better safety.  AHRQ-funded researcher, Pascale Carayon, Ph.D., has translated this expertise to health care by examining the safety impact of day-to-day processes among patients, clinicians, and health technology.

As an industrial and systems engineer, Dr. Carayon, the Procter & Gamble Bascom Professor in Total Quality at the University of Wisconsin-Madison, has used AHRQ funding to devise solutions to previously hidden patient safety risks using a human factors and systems engineering perspective.  

This approach takes a comprehensive look at a complex system that goes beyond fixing a single element, such as a tool or technology, to re-thinking how it interacts within the entire system and the many people who use it.  For example, this framework would analyze a pre-surgery checklist not only for its completeness, but also for its impact on workflow and team communications.

Dr. Carayon’s AHRQ-funded work applies human factors and systems engineering and human factors analysis to clinician and patient interactions across delivery settings. These interactions increasingly rely on health technology such as electronic health records (EHRs), clinical decision support (CDS) systems, computerized physician order entry systems, and others.  

In her latest AHRQ grant, Dr. Carayon is leading a multi-disciplinary effort to engineer safe care “journeys” for vulnerable older patients treated at hospital emergency departments (EDs) for falls or suspected urinary tract infections. These patients are at higher risk for patient safety issues that can require repeated ED visits or hospital stays, including additional falls, blood clots, healthcare-associated infections, and overuse of antibiotics or other drugs.

Working with colleagues from the University of Wisconsin’s schools of medicine and public health, engineering, pharmacy, and nursing, as well as its hospital system, Dr. Carayon will create a “patient safety passport” that helps clinicians identify and prevent risks that vulnerable patients often face after an ED visit. 

Like a travel passport that shows the places where a traveler has visited, the patient safety passport (in electronic or print form) will show where a patient has been treated and the potential patient safety events that might occur, such a newly prescribed drug that could increase the risk for falls. The 4-year grant to guide safe care journeys will be tested and implemented at an AHRQ-funded Patient Safety Learning Laboratory at the University of Wisconsin.

Dr. Carayon also is using human factors and systems engineering to better integrate clinicians’ information and workflow needs into CDS systems to prevent and diagnose blood clots. 

In this AHRQ-funded project that ends in 2019, Dr. Carayon is collaborating with human factors engineers and physicians at four hospitals where she evaluated the cognitive and teamwork factors involved in preventing and diagnosing blood clots.  This input has helped her develop new design requirements that are currently embedded into a CDS system that supports the diagnostic pathway of blood clots among ED patients. Early results of the CDS usability evaluation are showing the value of incorporating human factors-based design.   

 Although her AHRQ-funded study focused on improving CDS workflow to support blood clot diagnosis in the ED specifically, Dr. Carayon hopes to expand this approach to address other conditions and preventable complications.

In 2016, Dr. Carayon received the John M. Eisenberg Patient Safety and Quality Award in recognition of her contributions to patient safety using human factors and systems engineering concepts and methods.  The annual award from the Joint Commission and the National Quality Forum recognizes major achievements by individuals and organizations to improve patient safety and quality improvement. She is a Fellow of the Human Factors and Ergonomics Society and the Chair of the National Academies of Sciences, Engineering, and Medicine’s Board on Human-Systems Integration. 

Principal Investigator: Pascale Carayon, Ph.D.
Institution: University of Wisconsin-Madison
Grantee Since: 2001
Type of Grant: Various

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Page last reviewed March 2019
Page originally created March 2019
Internet Citation: Using a Human Factors and Systems Engineering Framework to Build Safer Patient Care Processes. Content last reviewed March 2019. Agency for Healthcare Research and Quality, Rockville, MD.
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