Statement on Human Factors Engineering and Patient Safety

Developed by: Committee on Patient Safety and Education
Original Approval: October 15, 2025

Human factors engineering or ergonomics (HFE) is an evidence-based scientific discipline that explores the interrelationships between humans, the tasks they perform, the tools they use, the physical environment, and the wider social, organizational, and regulatory environments in which they live and work.¹ 

The integration of HFE principles in the complex perioperative environment has tremendous potential to improve patient safety. HFE acknowledges the expertise required to deliver care successfully in complex, high-risk, time-critical situations with incomplete information. An HFE-centric approach sees ‘human error’ as a consequence of systems failures, offering many opportunities for improvement. HFE can help explain why variations from established protocols occur, and whether standardization could be productive. It can help develop and evaluate technologies, displays, controls, devices, and software to be most effective and least error-inducing. Continuous, deliberate examination of systems and processes that are working well can help to understand and encourage the activities that create safety and improve performance within the perioperative environment.^2,3,4 HFE practice applies this knowledge to the design of work systems in order to improve effectiveness and the well-being of the individuals, and the overall performance of the system. 

The value of developing human factors specialization in health care is acknowledged by organizations including the Institute for Healthcare Improvement, the Accreditation Council for Graduate Medical Education (ACGME), and the American Board of Anesthesiology (ABA).^8,9,10 The inclusion of adherence to human factors design principles as part of the Centers for Medicare & Medicaid Services’ (CMS) Patient Safety Structural Measure (PSSM) for acute care hospitals recognizes the importance of HFE expertise in improving health care.¹¹ The Human Factors and Ergonomics Society (HFES), the professional body for HFE in the United States, welcomes clinicians as affiliate members and opportunities to partner clinicians with qualified practitioners in this field.

A basic understanding of human factors, combined with insights from experts in the field, can improve safety education, create better work environments, and enhance patient care processes and outcomes.^12-14 Anesthesiologists should consider partnering with Human Factors Experts to identify and implement strategies to do the following¹⁵:

• Reduce incidence of errors and near-misses
• Design and evaluate health care devices
• Develop procedures, policies, and protocols based on how work is done versus work as imagined
• Optimize physical displays and controls to enhance awareness and decision making
• Reimagine the physical environment to improve safety for and enhance productivity of frontline clinicians
• Improve human cognition, decision making, performance, and well-being in the perioperative setting

In summary, the contribution of human factors professionals to anesthesiology practice can help us mitigate risk and improve patient safety.¹⁶

^References:

1. Karsh, B.T., Holden, R.J., Alper, S.J. and Or, C.K.L., 2006. A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. BMJ Quality & Safety, 15(suppl 1), pp.i59-i65.
2. Kuziemsky C. Decision-making in healthcare as a complex adaptive system. Healthc Manage Forum 2016;29(1):4-7 doi:10.1177/0840470415614842
3. Ruskin KJ, Dutton RP, Clebone Ruskin A. Curr Opin Anaesthesiol 2023;36(6):652-656 doi:10.1097/ACO.0000000000001289
4. Glover WJ, Nissinboim N, Naveh E. Examining innovation in hospital units: a complex adaptive systems approach. BMC Health Services Research 20, 554 (2020) doi:10.1186/s12913-020-05403-2
5. Lomax S, Sutcliffe J, Catchpole K. Implementing human factors in anaesthesia. Anaesthesia. 2023;78(7):916-917. doi:10.1111/anae.16006
6. Weinger MB, Gaba DM. Human factors engineering in patient safety. Anesthesiology. 2014;120(4):801-806. doi:10.1097/ALN.0000000000000144
7. Bailey CR, Shorrock S, Fong K. Human factors and ergonomics. Br J Hosp Med (Lond). 2023;84(6):1-4. doi:10.12968/hmed.2023.0142
8. National Steering Committee for Patient Safety. Safer Together: A National Action Plan to Advance Patient Safety. Boston, Massachusetts: Institute for Healthcare Improvement;2020
9. ACGME Program Requirements for Graduate Medical Education in Anesthesiology effective July 2023 https://www.acgme.org/globalassets/pfassets/programrequirements/040_anesthesiology_2023.pdf
10. Carayon P, Kleinschmidt P, Hose BZ, et al. Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents In: Donaldson L. Textbook of Patient Safety and Clinical Management. Springer 2021 Chapter 7
11. Center for Medicare & Medicaid Services. https://public-inspection.federalregister.gov/2024-17021.pdf#page=1342 
12. Kelly FE, Frerk C, Bailey CR, et al. Human factors in anaesthesia: a narrative review. Anaesthesia 2023;78:479-490
13. Kelly FE, Frerk C. Bailey CR, et al. Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals. Anaesthesia 2023;78:458-478
14. Chartered Institute of Ergonomics & Human Factors. NHS Health Education England. Human Factors and Healthcare. 2019
15. Fermin L, Lobaugh L, Parr KG, Currie M. The role of human factors engineering in patient safety. Current Opinion in Anaesthesiology 2024;37(6):683-688 doi: 10.1097/ACO.000000000000143
16. Catchpole K, Bowie P, Fouquet S, Rivera J, Hignett S. Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare. Int J Qual Health Care 2021; 33 (Supplement_1):13-18. doi:10.1093/intqhc/mzaa108