Human factors in patient safety: Review of topics and tools: Report to WHO, Geneva

Çakıl Agnew, Rhona Flin, Jeanette Jackson, Michelle Raduma

Research output: Book/ReportCommissioned report


This report was prepared for WHO Patient Safety’s Methods and Measures for Patient Safety Working Group.

It provides a basic description of major topic areas relating to human factors relevant to patient safety, with some indication of possible tools that can be used in a healthcare workplace for measurement or training of these topics. First an explanation of the human factors approach is provided. An organising framework is presented to provide a structure for the discussion of the topics, by categorising them as follows:

i) Organizational/ Managerial, ii) Team, iii) Individual, iv) Work environment.

Wider social factors and the central role of the patient are also acknowledged but these aspects of the healthcare system are not explicitly covered.

Ten topic areas within these four categories are described: organizational culture, managerial leadership, communication, teamwork, team leadership, situation awareness, decision making, stress, fatigue, work environment.

A selection of tools for education, measurement or training these human factors topics is described. Some of these may be suitable for application in developing, as well as
developed, countries.
Original languageEnglish
Place of PublicationGeneva, Switzerland
PublisherWorld Health Organization
Commissioning bodyWorld Health Organization
Number of pages55
Publication statusPublished - Apr 2009

Publication series

NamePatient Safety
PublisherWorld Health Organization


  • patient safety
  • Human factors


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