Human factors: How to use them to improve clinical outcomes

Identify the human factors – fatigue, stress, distraction – that can cause medical errors and change your organization’s culture


It was a busy night for the EMS crew, and they were weary from previous calls, especially one that involved a child. They thought all their equipment was present and working when they rushed out of the emergency room to respond to another call because their district was out of ambulances. However, when they needed their cardiac monitor, it was missing. The chain of untoward events started when the crew quickly checked the equipment before leaving for the call. On another call, the wrong concentration of epinephrine was given. Because the crew didn’t take the time to do a medication check, the providers will never know if their oversight hastened the death of their patient.

These are system issues, which are impacted by what we call human factors. Wikipedia defines human factors as “the application of psychological and physiological principles to the engineering and design of products, processes and systems. The goal of human factors is to reduce human error, increase productivity, and enhance safety and comfort with a specific focus on the interaction between the human and the thing of interest.”

Where to Start?

Paul Misasi Image: The Center for Patient Safety
Paul Misasi Image: The Center for Patient Safety

Humans make mistakes for many reasons including fatigue, distractions, complacency, stress, lack of teamwork, lack of knowledge or awareness, norms – and the list goes on. Some leaders may think the numerous reasons are too overwhelming and don’t know where to begin to address them. But organizations that want to achieve high reliability must tackle the task, knowing it will take months to years to change their culture.

Start by studying human factors and learning how they affect the patient care provided by your clinicians. Share that knowledge with your providers, asking for their input and discuss why they believe errors occur. Select one factor and discuss why it happens; then problem-solve to create solutions. Apply those solutions to your environment, protocols, procedures, equipment and training.

For example, you might discuss fatigue, a well-known characteristic of EMS providers which contributes to errors. Why does it happen? Clinicians might say it’s long shifts, working multiple jobs, or stress brought on by the work itself. What can be done about it? Discuss staffing, the importance of sleeping and exercising regularly, implementing the expectation to ask others to check work in certain situations and add it to your protocols as a reminder. By addressing each of the human factors and how they impact patient care, you will redesign your systems, procedures and training, which will ultimately result in safer care.

CPS “Road to Reliability” webinar series

As part of its year-long Road to Reliability learning series, the Center for Patient Safety is offering a webinar on April 15 at 1 p.m. CST with Paul Misasi, deputy director of Operations at Sedgwick County EMS, who will share his doctoral research on the field of human factors and how they can guide quality improvement processes. He will provide examples of how human factors have improved the delivery of clinical care, and describe why some quality improvement efforts fail as a result of focusing on human error and misguided efforts of remediation.

About the speaker

Paul Misasi has been a paramedic for 16 years and currently serves as the deputy director of operations for Sedwick County Emergency Medical Service, the largest EMS agency in the state of Kansas. He is a doctoral candidate in Human Factors Psychology at Wichita State University. He holds a Masters degree in Emergency Health Services from the University of Maryland, Baltimore County; and a Masters degree in Psychology and Bachelors of Science in Health Service Organization & Policy from Wichita State University. He is the first paramedic/ambulance service manager to achieve certification as a certified professional in patient safety through the National Patient Safety Foundation, and is fourth to achieve this designation in the state of Kansas.

Misasi is engaged in a number of collaborative projects with Wichita State University and is co-editor/author of a CRC Press book, “Human Factors and Ergonomics of Prehospital Emergency Care.” He is currently co-investigator of a project with the Industrial & Systems Engineering Department with a goal to refine the way that EMS agencies measure crew workload.

Misasi is a driving force in his organizations' adoption of a systems approach to quality and safety improvement, and the just culture management philosophy. He brings an aviation background, including pilot licensure and education in crew resource management from Oklahoma State University, and is a strong proponent for incorporating CRM into the practice of prehospital and emergency medicine.

Among his research, he has validated a collaborative cross-check protocol (that he developed and implemented) for the prevention of medication errors in the out-of-hospital setting. The Medication Administration Cross-Check (MACC) has been recognized as a “best practice” in the delivery of prehospital care.

Visit the CPS’s “The Road to High Reliability” for additional information and to register. 

Additional safety culture resources

Learn more about creating a safety culture in EMS with these resources:  

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