Over the past several years, there has been an increase in interest in translating human factors knowledge and methods, primarily used in complex, event-driven, sociotechnical settings such as aviation, to health care. In this article, we overview the primary concepts in cognitive systems engineering that may aid in formulating interventions in a variety of diverse medical settings to reduce the likelihood of patient harm. To improve resilience in medication delivery, we propose immediately incorporating 3 key levers: (1) scenario-based design and evaluation of interventions, (2) advanced information visualization techniques to reduce data overload in the electronic medical record, and (3) explicit consideration and documentation of asynchronous, interdisciplinary teamwork support during software requirements analysis, including a workload shifting analysis. For long-term progress, we recommend investing in research to better understand technical work in health care, specifically task requirements in work domains and the trade-offs and strategies that workers use to meet these demands.
From the *VA Getting at Patient Safety (GAPS) Center, Cincinnati, OH; †Institute for Ergonomics, The Ohio State University, Columbus, Ohio; ‡Roth Cognitive Engineering, Brookline, MA; §Cognitive Technologies Laboratory, University of Chicago, Chicago, Illinois; ∥Health Center, University of Florida, Jacksonville, Florida; and ¶Department of Medicine, University of Cincinnati, Cincinnati, Ohio.
Correspondence: Emily Patterson, PhD, Ohio State University, 210 Baker Systems, 1971 Neil Ave, Columbus, OH 43210. (e-mail: firstname.lastname@example.org).