Hearing “Paging Dr. Strong” on the intercom system does not
necessarily mean the operator is summoning an actual Dr.
Strong. Some facilities use that code to call in the security
guards to deal with misbehaving patients or visitors. Code Silver
in one hospital may refer to “missing person” and in another
“somebody with a gun.” These codes might be standardized across a
hospital or a hospital system, but there is little
standardization across regions or states.
Rules for abbreviation use generally focus on medication
safety—identifying visual and textual ambiguities that may
confuse other medical professionals. The ISMP List of
Error-Prone Abbreviations, Symbols, and Dose Designations
includes items like IU that could appear like
IV or 10; and
DPT, which could stand for
One barrier to change is resistance by those who have not
experienced a bad event. Most of us were trained to learn from
our personal experience; quite useful in many situations,
especially when scientific evidence is weak or absent. Given the
vast variety of situations patients present with and the limits
of scientific evidence, there are many situations in which human
intuition and experience are valuable. You can often hear
experienced professionals say that they made a “gut” decision;
one made from instinct and intuition developed through their own
A frequent response to an adverse event is to retrain the staff.
However, training is often criticized as a very weak and
inappropriate response to problems, unlikely to result in
significant sustained improvement. That criticism is correct, to
A recent paper discusses the difference between appropriate and
inappropriate training from the human factors standpoint .
Training as the sole or primary intervention may be of marginal
value as system design issues are often part of the problem.
Henriksen K, Dayton E, Keyes MA, et alPatient Safety and Quality: An Evidence-Based Handbook for Nurses (Chapter 5). AHRQ Publication No. 08-0043, April 2008.
This Agency for Healthcare Research and Quality (AHRQ)
handbook examines the broad range of issues involved in
providing high quality and safe care in all health care
settings. This section of the guidebook provides a framework
for collaboration between health care and human
factors, and addresses the interdependent system factors that
underlie patient safety.
National Health Service Patient Safety First Campaign
This guide provides an introduction to the concept of human
health care and provides suggestions of how its elements can be
applied by individuals and teams working to improve patient
safety. It aims to build awareness of the importance
of human factors in making changes to improve patient
World Health Organization (WHO) Patient Safety has identified
human factors measurement tools falling into four categories:
organizational/managerial, team, individual, and work
environment. The tools within each category fall into numerous
categories, including communication, decision-making, and
James ReasonDepartment of Psychology, University of Manchester
The basic premise in the system approach is that humans are
fallible and errors are to be expected, even in the best
organizations. Errors are seen as consequences rather than
causes, having their origins not so much in the perversity of
human nature as in “upstream” systemic factors … Countermeasures
are based on the assumption that though we cannot change the
human condition, we can change the conditions under which humans
work … When an adverse event occurs, the important issue is not
who blundered, but how and why the defenses failed.