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Engineering Safe Practices Affinity Group

Background 

The National Action Alliance established the Engineering Safe Practices Affinity Group to make healthcare safer by design by identifying scalable opportunities for engineering safety into key healthcare practices—one of the Alliance’s five Aims. Read more about the Aims and the approach the Alliance is taking to achieve them. 

Strategies to Engineer Safety into Healthcare Delivery 

Although it has long been used to improve safety in , human factors engineering is often underutilized in healthcare. However, safety engineering offers the opportunity to lessen reliance on individuals and build healthcare delivery systems that are safe, effective, and efficient. 

The National Action Alliance for Patient and Workforce Safety identified the need to facilitate the widespread adoption of strategies that make it more difficult for people to make errors in care delivery or experience a work-related injury using human factors engineering principles. This document provides an overview of some safety engineering principles, strategies, change concepts, and examples for those seeking to make their systems safer.

Strategies and Change Concepts 

Rationale: Safety engineering is based on a proactive approach using both prospective and retrospective analysis tools accompanied by constant surveillance. The identification of workarounds may be a signal that a process is not functioning well. Advances in knowledge and changing expectations and priorities are inevitable. Healthcare organizations can use established methods and tools to incorporate hazard anticipation, prevention, and mitigation into routine operations.

Opportunities: Routinely assess processes for potential gaps, changes, or unidentified opportunities and redesign outdated processes. Conduct routine and ad-hoc briefings and debriefings to assess and respond to healthcare worker, patient, and family concerns and early warnings. Establish standard contingency plans for high-risk failures such as cybersecurity breaches, natural disasters, and mass casualty events. Develop processes to adapt, communicate, and continue operations during unexpected conditions, such as changes in the availability of medication, equipment, supplies, and staff. 

Resources

  • includes strategies to identify risks and hazards and prevent/control work-related injury.
  • .
  • to identify and plan for potential supply gaps.*
  • Institute for Healthcare Improvement .

Tools

Examples

 * Indicates an AHRQ-supported tool or resource

Rationale: Organizing processes, supplies, equipment, and technology interfaces with human factors principles can reduce the risk of error and harm. Such approaches make it easier to carry out work as intended, improving efficiency and job satisfaction while reducing stress.

Opportunities: Optimize and standardize equipment interfaces, medication carts, workstations, and emergency and resuscitation supplies. Provide and periodically modify visual, auditory, and/or tactile cues for hazards. Optimize menu choices while minimizing unnecessary alerts. Use simulation to improve processes and perform leadership rounds to engage frontline staff.

Resources

Tools

  • Mapping method for complex, non-linear functions and relationships: .
  • to address Electronic Health Record safety.

Examples

  • Redesign.
  • Shrink-wrapping paralytic medications as a visual and tactile cue.
  • .*

 * Indicates an AHRQ-supported tool or resource

Rationale: Structuring the built environment to minimize physical hazards and reduce the physical burden on staff will improve workflows, promote safety, and support efficiency. 

Opportunities: Design patient care spaces to facilitate patient care and minimize hazards to healthcare workers (e.g., tripping hazards). Design spaces for patients with behavioral health conditions that provide safety for patients and healthcare workers. Include safety engineering expertise for renovations and new construction.

Resources

Tools

Examples

 * Indicates an AHRQ-supported tool or resource

Rationale: Patients are vulnerable at the many intersections of care transitions, particularly the reconciliation of medications and information captured in electronic health records. Transitions may be within or between facilities and providers, a patient’s home, or other healthcare delivery settings. 

Opportunities: Evaluate and improve the accuracy and effectiveness of handoff processes and use structured tools or processes for handoff communication and medication reconciliation. 

Resources

Tools

Examples

 * Indicates an AHRQ-supported tool or resource

Rationale: Individual- and team-based continuous learning supported by iterative feedback is essential for high reliability in healthcare. There are many learning modalities, both formal and spontaneous. Psychological safety and opportunities for reflection both support learning.

Opportunities: Implement purposeful briefings or huddles at tiered levels (e.g., unit, team, shift) and incorporate debriefings after procedures/events (“hot”) and as regularly scheduled activities (“cold”) to address routine processes as well as instances of exceptionally poor or good outcomes. This  approach assumes that everyday performance variability provides the adaptations needed to respond to varying conditions and that both success and failure offer learning opportunities. Incorporate training opportunities for team members to develop debriefing facilitation skills. Establish informal and formal reporting systems to identify successes as well as harmful events, errors, near-miss events, and unsafe conditions with the option of anonymous reporting. 

Resources

  • .

Tools

Examples

* Indicates an AHRQ-supported tool or resource 

鶹Ƶwishes to acknowledge and thank the following people and organizations for sharing their expertise on the Affinity Group:

ContributorOrganization
Pascale Carayon, Ph.D., Professor Emerita, Department of Industrial & Systems Engineering; Founding Director, Wisconsin Institute for Healthcare Systems Engineering  University of Wisconsin–Madison  
Chris DeRienzo, M.D., M.P.P., Senior Vice President, Chief Physician Executive  American Hospital Association  
Rollin J. “Terry” Fairbanks, M.D., M.S., Senior Vice President and Chief Quality & Safety Officer  MedStar Health  
Lillee Gelinas, D.N.P., R.N., CPPS, FAAN, Assistant Professor, Medical Education & Health Systems Science; Patient Safety Director  Texas College of Osteopathic Medicine, The University of North Texas Health Science Center  
Ayse Gurses, Ph.D., M.S., M.P.H., Director of Armstrong Institute Center for Health Care Human Factors and Professor of Anesthesiology & Critical Care Medicine  Johns Hopkins University, Malone Center for Engineering in Healthcare  
Anjali Joseph, Ph.D., Endowed Chair in Architecture & Health Design  Clemson University and Spartanburg Regional Health System  
Scott Lucas, Ph.D., PE, Vice President of Device Safety  ECRI  
Elizabeth Mort, M.D., M.P.H., Chief Medical Officer  The Joint Commission  
Christine Sinsky, M.D., Vice President for Professional Satisfaction  American Medical Association  
Rupa S. Valdez, Ph.D., M.S., Associate Professor of Public Health Sciences & Engineering Systems and Environment, Department of Public Health Sciences & Department of Systems and Information Engineering  University of Virginia  
Kayla Waldron, Pharm.D., M.S., BCPS, Director of Medication Use and Quality Improvement  American Society of Health-System Pharmacists  

Federal Partners

ContributorOrganization
Martha Betz, Ph.D., Associate Director of Post Market Programs, Center for Devices and Radiological Health  Food and Drug Administration  
Lauri Hicks, D.O., FACP, Chief, Medical Product Safety Branch, Division of Healthcare Quality & Promotion  Centers for Disease Control and Prevention  
David Hunt, M.D., Medical Director, Patient Safety  Assistant Secretary for Technology Policy / Office of the National Coordinator for Health Information Technology

National Action Alliance Facilitators

ContributorOrganization
Ellen S. Deutsch, M.D., M.S., FACS, FAAP, FSSH, Medical Officer, Division of General Patient Safety, Center for Quality Improvement and Patient Safety  Agency for Healthcare Research and Quality  
Fran Griffin, M.P.A., RRT, Consultant  Ripple Effect  
Jennifer Trallo Schreiber, M.S.N., M.B.A., R.N., CPPS, CPHQ, Principal Program Analyst  Ripple Effect  
Page last reviewed April 2025
Page originally created September 2024

Internet Citation: Engineering Safe Practices Affinity Group. Content last reviewed April 2025. Agency for Healthcare Research and Quality, Rockville, MD.
/action-alliance/engineering-safety-practice/index.html

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