The Doctor’s Advocate | First Quarter 2023
Perspectives from the CMO

Building a Culture of Safety in Healthcare, Part Three: Human Factors Engineering

David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors

Medical professionals are human, and humans make mistakes. When we recognize this simple fact and act on it as we design our physical treatment spaces, our workflows, and our approaches to training, we contribute to a culture of safety in healthcare.

We also participate in what Amish Aghera, MD, an emergency medicine physician and simulation training leader at Maimonides Medical Center, has described as “a paradigm shift.”1 Increasingly, we recognize that it is simply unsafe to demand superhuman stamina and consistency from ourselves or others while working in high-stress, sometimes chaotic conditions—especially where systems do not support our success and protect patient safety. Still, given our training and surroundings, the punishing cycle of unrealistic expectations can be hard to break.

Admitting that we are human will not harm our patients—it will protect them.

To Err Is Human, and So Is to Design

Human factors engineering (HFE) is an extension of user-centered design. In that spirit, HFE means designing our tools, machines, spaces, and systems for the tasks we actually need to complete—while taking into account human strengths and limits.2 HFE creates systems with realistic expectations for human cognitive load and attention spans, as well as how people actually interact with their physical environments.3

One example of HFE in action is putting hand-washing stations and hand sanitizer dispensers where they are most easily accessible: within treatment spaces and in transitional spaces, instead of in out-of-the-way corners where people have to make a special trip to reach them. Researchers have repeatedly found that this common-sense design feature impacts medical professionals’ hand hygiene compliance—which we know is a driver for infection prevention.4

Do your own workspaces have physical features that are hindering your work, not helping it? If you are in a leadership role, try surveying those in frontline patient care. They will know what needs fixing. Some of the items could be as basic and as vital to patient outcomes as moving the hand-washing stations or adapting medication carts so that their layout better prevents medication errors.

Design Systems for Depth of Defense

My colleagues and I recently published an article in the Journal of the American College of Surgeons that reviews our experience with preventing retained surgical items (RSI). Over a 10-year period, we saw a 50 percent drop in RSI using radiofrequency (RF)-labeled sponges/lap pads and teamwork training. Since most of the RSI reduction was seen in the labeled sponges (as opposed to other, unlabeled items, like needles and instruments), we presume most of the impact was from the RF labeling.5

This is a great example of HFE applied to the OR, where counting—despite being subject to human fallibility—is the traditional way of preventing RSI. Now we use a belt-and-suspenders approach, with nurses counting plus RF detecting. This strategy is what engineers would call depth of defense.

To Educate, Simulate

We can apply the principles of HFE to professional development by aligning more of our professional training with how most people retain what they’ve learned.

For example, when testing revealed that medical residents were retaining a lower proportion of presentation-based training content than Dr. Aghera had hoped, he thought, “Am I just bad at this thing? Are our residents bad?” After reflection, he concluded, “It just has to do with how we think as human beings.” From there, seeking training methods “to keep people engaged,” Dr. Aghera honed his skills in simulation training.1

Researchers from various medical professional bodies have confirmed the effectiveness of simulation for learner retention and patient safety,6 and Dr. Aghera could witness the results unfolding in real time: “It was clear, from the very beginning,” he says of his learners, that they were “really engaged . . . because the activities are relevant to their day-to-day practice.” Trainees began reporting back that the simulation lab had provided them an opportunity to encounter some “hiccups,” so that then in an actual treatment situation with a patient, “everything played out smoothly.”1

Keep Simulating

Midcareer clinicians can experience similar benefits with simulation training: “It’s a curious thing,” says Eric Barna, MD, MPH, a hospitalist and physician advisor at Mount Sinai Hospital, that “once we make headway into our medical careers . . . we rarely have the opportunity to assess our skill sets.” Dr. Barna participated in a communication skills training that was tailored to the unique challenges of hospitalist practice, in which physicians must quickly establish relationships with patients already at critical points of care. Mount Sinai has since expanded this successful program.7

Find Allies and Identify First Projects

Whether launching a simulation program or recruiting resources for an HFE project related to physical space, Dr. Aghera advises considering organizational factors: “Who are the people who are going to get things moving at a higher administrative level . . . and who are you going to work with? Who’s that working coalition, so to speak?”1

He also recommends starting with a project that will easily attract recruits. A simulation program might offer what learners are excited to learn—and only then pivot to what teachers think they should teach: “Trying to find projects that people are excited about . . . was a great way for us to start, getting people into the simulation center . . . starting with things like airway management. They realize, hey, this is really useful. And then when they come back, you can do communication training.”1

Thinking About How We Think

HFE sets medical professionals up for success by aligning our imagined workday with its physical reality. HFE helps us design our workspaces for how we actually move through them. It also helps us pivot from how we might imagine we learn to how we actually retain more content.

Dr. Aghera describes self-observation as the theme that links simulation training to HFE’s applications for physical spaces. After trainees’ first simulation experience, he says, “They’ve started to get this idea of reflection and thinking about how they practice.” It’s this reflection that leads to helpful actions in improving healthcare systems for patient safety: “That’s part of what human factors is about. Right? It’s about thinking how we think, and then putting systems in place to help augment that.”1

To learn more about human factors engineering, simulation training, and organizational change, listen to my interview with Dr. Aghera through the Leading Voices in Healthcare podcast.


  1. Feldman D. Interview with Amish Aghera, MD: To build a culture of safety, use human factors engineering. Leading Voices in Healthcare TDC Group.
  2. Gosbee J. Human factors engineering and patient safety. Qual Saf Health Care. 2002;11:352-354.
  3. Human factors in health care. Armstrong Institute for Patient Safety and Quality. Johns Hopkins Medicine.
  4. Pennathur PR, Herwaldt LA. Role of human factors engineering in infection prevention: gaps and opportunities. Curr Treat Options Infect Dis. 2017;9(2):230-249.
  5. Kaplan HJ, Spiera ZC, Feldman DL, et al. Risk reduction strategy to decrease incidence of retained surgical items. J Am Coll Surg. 2022;235(3):494-499. doi:10.1097/XCS.0000000000000264
  6. Hughes KE, Hughes PG. Medical simulation fellowships. StatPearls.
  7. Barna E. Physician learning must evolve to keep healthcare workforce prepared. The Doctors Company. Published May 2018. 

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

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