Author: Frank Federico, Content Director, Institute for Healthcare Improvement, ffederico@ihi.org

Reviewer: Valerie Pracilio, Project Manager for Quality Improvement in the Department of Health Policy and student in the Public Health Program at Thomas Jefferson University

Description

Maybe the floor’s wet and slippery. Maybe the cash register is confusingly labeled. Maybe medications are hard to tell apart. Everywhere you look — both in health care and in ordinary retail settings — you can spot circumstances that make it easy for regular people to make mistakes. In this exercise, you’ll go out and analyze everyday situations to determine what human factors issues are at play. You’ll also decide what interventions should be introduced to minimize the opportunities for mistakes.

Note: For this exercise to be most effective, participants should have already completed four lessons offered by the IHI Open School: Patient Safety 101, Lesson 1, and Patient Safety 102, Lessons 1-3. 

Learning Objectives

After completing this exercise, participants will be able to:

• Identify human factors in everyday settings.
• State how such factors contribute to errors.
• Develop strategies to minimize or prevent error.