infection control & hospital epidemiology july 2018, vol. 39, no.
commentary
Human Factors and Systems Engineering: The Future of
Infection Prevention?
Priti R. Patel, MD, MPH, Alexander J. Kallen, MD, MPH
(See article by Leback et al, pages 841-848.)
Human factors is a discipline that utilizes the “under-
standing of interactions among humans and other elements of
a system” and methods and design principles to “optimize the
human well-being and overall system performance.”1 The field
traces its origins to the study and design of human operator use
of military systems and equipment.2 Human factors approa-
ches to certain subtopics such as accidents, human error, and
warning systems have been used to improve safety in industries
including aviation, aerospace, transportation, and mining. The
same principles and methods can also be applied to improving
safety in healthcare systems, particularly as new technologies
are incorporated into healthcare delivery, in the form of
medical and surgical devices, health informatics, electronic
medical record clinical decision supports, and health
monitoring devices.
In this issue, Leback et al3 describe results of injection-
safety–focused observations and interviews conducted in
a range of outpatient clinical settings within a single health
system. Challenges to basic injection safety standards
(eg, syringe reuse for >1 patient) persist in many healthcare
settings,3,4 necessitating a thorough understanding of barriers
to safe practices and innovative approaches to overcome such
barriers, especially in outpatient clinics. Clinics in this study
included adult and pediatric primary-care clinics, dialysis
centers, urgent care clinics, imaging clinics, and outpatient
procedure clinics. Observations of injection practices were
conducted, and interviews of staff were also performed to
understand barriers and facilitators to injection safety in the
clinics. The authors utilized a human factors approach to
evaluate interview responses and connected themes to the
observation data. The Systems Engineering Initiative for
Patient Safety (SEIPS)5 framework was used to design inter-
view questions and classify barriers and facilitators into the
SEIPS categories of: workflow, persons, organization, envir-
onment, and tools and technology.
This study contributes several pertinent findings. First,
generally good adherence to recommended safe injection
practices was observed across clinics, including proper use of
single dose vials (ie, 1-time use for 1 patient only). However,
Affiliations: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
Received April 24, 2018; accepted April 28, 2018
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0012. DOI: 10.1017/ice.2018.122
opportunities for improvement were identified, such as keep-
ing multidose vials out of patient care areas and cleansing septa
of vials prior to accessing. Second, according to the authors,
the observations conducted in the study uncovered a
greater number of gaps compared to routine infection
prevention site visits of these same clinics that have relied upon
self-reports of practice. This finding reinforces the importance
of direct observations of practice as part of on-site assessments,
which is a component of the CDC Guide to Infection
Prevention in Outpatient Settings6 and is essential to any
evaluation of infection control practice.
Third, and perhaps most enlightening, is the analysis of the
interview responses. For most SEIPS categories, roughly half of
responses were coded as barriers. The exception was the tools
and technologies category, for which only 27% of responses
were barriers. All barriers were specifically reported as ones
that make it difficult to give injections safely. The most
frequently reported barrier, in any category, to giving safe
injections was feeling rushed or high patient turnover. While
perhaps not surprising, it should be alarming that staff across
different clinic types reported this pervasive issue that has such
potential to cause medical errors. Important barriers related to
the environment were small patient-care areas and medication
rooms, and an excessive distance between these 2 areas.
Notable facilitators were the availability of injection supplies in
work areas, and a commonly reported facilitator in the cate-
gory of workflow was preparing medications in advance. The
latter is a logical strategy to avoid errors when feeling rushed,
yet it is at odds with recommendations to prepare medications
as close in time as possible to their administration. This is
particularly true if staff are engaging in batch preparation of
medications for multiple patients, a practice that has con-
tributed to outbreaks of infection.7,8 The Institute for Safe
Medication Practices (ISMP) has recommended avoiding the
need for vial manipulation and syringe preparation in the
clinic setting through the use of manufacturer-prefilled or
pharmacy-prepared prefilled syringes for i.v. push medications
and flush.9 When available, the use of “ready-to-administer”
medications can save time, improve workflow, and reduce
opportunities for errors and contamination. In this study, many
850 infection control & hospital epidemiology july 2018, vol. 39, no. 7
of the reported barriers and facilitators across clinic types
demonstrate that some measures intended to improve safety of
practices (eg, separation of medication preparation and clean
supplies from patient care areas) can create challenging workflows
and result in (at a minimum) staff perceptions that the injections
are less safe. An ideally designed system, environment, and work
context would enable safe injections without hindering workflow.
In this way, the human factors approach mirrors a widely
accepted hierarchy of public health interventions, in which a
high likelihood of positive impact exists when the individual’s
context can be modified so that default decisions align with
healthy and desired actions (eg, those that promote injection
safety) and when the effort level required by an individual
(eg, to check a medication vial expiration date) is lowest.10 In
contrast, education and training, which are often the focus of
infection prevention interventions, are less likely to result in
positive or sustained impact in the absence of other interven-
tions that address broader systems issues.10–12
The human factors approach as applied for the purpose
of infection prevention and control has advantages and
disadvantages (Table 1). The most compelling advantage is the
potential to identify major underlying causes and contributors
to a problem. Just as Leback et al discovered that feeling rushed
might have a more powerful influence on practices than injec-
tion safety knowledge, training, supplies or technology, there are
opportunities to gain important insights into why lapses in
other important infection prevention practices can occur, and
how to intervene. This approach considers multiple broad
outcomes simultaneously and assumes that staff engagement
and job satisfaction are integrally linked to positive organiza-
tional outcomes (ie, recognition and profitability) and health
and safety outcomes such as healthcare-associated infections
(HAIs).5 The idea that improvements in staff well-being can
serve as a “rising tide” to positively affect other outcomes in
healthcare has obvious merits.
The human factors approach has 2 potential disadvantages:
its resource-intense nature and generalizability of evaluation
findings and solutions. Detailed evaluations can be expensive
table 1. Human Factors Approach to Infection Prevention
Advantages
∙ Considers multiple, interrelated factors and outcomes, including
staff well being
∙ Acknowledges complexity of healthcare systems and processes
∙ Identification of “upstream” causes and more sustainable solutions
∙ Demonstrated success in promoting safety in other industries
∙ Applicable to range of issues that might influence HAIs (eg, from
availability of supply kits to how teams work and communicate, to
cognitive load and interruptions)
Disadvantages
∙ Potentially resource intensive
∙ Low generalizability of findings
∙ Availability of human factors expertise (and involvement during
implementation and post-implementation phases)
∙ Assumes “persons” are primarily employees of the organization
and time-consuming, and ready solutions to certain issues,
such as physical infrastructure, staffing, or workload, might
not exist. Human factors experts with experience in healthcare
are not available to every healthcare system,11 and they might
not be available at all to freestanding clinics that lack hospital
affiliation. Because human factors assesses the interactions
among humans, technology, and environments within
systems, these factors can all differ in each clinic, hospital unit,
or other local healthcare setting, the generalizability of research
findings is potentially undermined. Despite this, Leback et al
identified common themes across different clinic types, and it
is possible that some settings (eg, outpatient dialysis clinics
with shared corporate ownership) might have many more
similarities than differences in factors such as tasks, environ-
ments, technology, and organization.
Strategies based upon human factors principles have long
been employed in the field of infection prevention. Checklists,
implementation bundles, and other tools have been famously
adopted and incorporated as staples of device-associated
infection prevention.13–15 Communication tools, strategies
and technologies are also in use to improve the transfer
of information that is essential to infection control or
antimicrobial stewardship.16–18 Usability testing of the
human-machine interaction is conducted by manufacturers of
reprocessing machines or environmental disinfection devices.
In addition, efforts exist to integrate infection prevention
considerations into healthcare facility design, albeit largely
focused on hospital settings.19 Collaborations between
healthcare epidemiologists and human factors engineers, and
inclusion of human factors experts in infection prevention and
control efforts, appears to be a more recent phenomenon.
Rock et al20 utilized the SEIPS model and conducted a human
factors evaluation to discern opportunities to improve
environmental cleaning and disinfection of patient rooms. The
evaluators identified multiple strategies in the domains of
persons, tasks, organization, environment, and tools and
technology that could result in desired improvements to
patient room disinfection. The human factors and systems
engineering approach has also been utilized to conduct several
other evaluations of barriers and facilitators to infection pre-
vention practices (eg, hand antisepsis and C. difficile preven-
tion) and clinical guideline adherence.21–23 In these examples,
human factors has advanced our knowledge of why and how
systems, and the humans operating within those systems, fail
to prevent HAIs. What is needed now are additional demon-
strations that such findings can directly inform strategies and
interventions that positively impact primary outcomes, such as
HAIs or antimicrobial resistance.
Adherence to standard practices and interventions that have
been shown to prevent infections in healthcare settings
remains a critical challenge. The work done by Leback et al
extends the science of human factors and systems engineering
to outpatient settings, where adherence gaps may be greatest,
and it highlights the promising nature of these approaches for
improving patient care and outcomes. Ultimately, the value of

human factors approaches to infection prevention will depend
on the ability not only to just identify and describe challenges
to best practice but also to successfully overcome challenges
through effective interventions that improve adherence and
reduce HAIs.
a ck n ow le d g m e n t s
The authors wish to thank Dr Joseph Perz for his insights and suggestions.
The findings and conclusions in this report are those of the authors and do not
necessarily represent the official position of the Centers for Disease Control
and Prevention.
Financial support: No financial support was provided relevant to this article.
Potential conflicts of interest: All authors report no conflicts of interest rele-
vant to this article.
Address correspondence to Priti R. Patel, MD, MPH, Division of Health-
care Quality Promotion, Centers for Disease Control and Prevention, 1600
Clifton Rd, MS A-31, Atlanta, GA 30333 (ppatel@cdc.gov).
references
1. Definition and domains of ergonomics. International Ergo-
nomics Association website. iea.cc/whats/index.html. Accessed
April 8, 2018.
2. History. Human Factors and Ergonomics Society website.
https://www.hfes.org/ContentCMS/ContentPages/. Accessed
April 8, 2018.
3. Leback C, Johnson DH, Anderson L, Rogers K, Shirley D,
Safdar N. Barriers and facilitators to injection safety in ambulatory
care settings. Infect Control Hosp Epidemiol 2018;39:841–848.
4. Kossover-Smith R, Coutts K, Hatfield KM, et al. One needle, one
syringe, only one time? A survey of physician and nurse knowl-
edge, attitudes, and practices around injection safety. Am J Infect
Control 2017;45:1018–1023.
5. Carayon P, Schoofs Hundt A, Karsh BT, et al. Work system
design for patient safety: the SEIPS model. Qual Saf Health Care
2006;15(Suppl I):i50–i58.
6. Guide to infection prevention for outpatient settings: minimum
expectations for safe care. Centers for Disease Control and Preven-
tion website. https://www.cdc.gov/hai/settings/outpatient/outpatient-
care-guidelines.html. Updated 2016. Accessed April 8, 2018.
7. Ross K, Mehr J, Carothers B, et al. Outbreak of septic arthritis asso-
ciated with intra-articular injections at an outpatient practice—New
Jersey, 2017. MMWR Morb Mortal Wkly Rep 2017;66:777–779.
8. See I, Nguyen DB, Chatterjee S, et al. Outbreak of Tsukamurella
species bloodstream infection among patients at an oncology
clinic, West Virginia, 2011–2012. Infect Control Hosp Epidemiol
2014;24:300–306.
9. Institute for Safe Medication Practices (ISMP). ISMP safe prac-
tice guidelines for adult IV push medications: a compilation of
safe practices from the ISMP Adult IV Push Medication Safety
human factors engineering in infection prevention 851
Summit. ISMP website. https://www.ismp.org/sites/default/files/
attachments/2017-11/ISMP97-Guidelines-071415-3.%20FINAL.
pdf. Published 2017. Accessed April 17, 2018.
10. Frieden TR. A framework for public health action: the health
impact pyramid. Am J Public Health 2010;100:590–595.
11. Hettinger AZ, Fairbanks RJ, Hegde S, et al. An evidence-based
toolkit for the development of effective and sustainable root cause
analysis system safety solutions. J Health Risk Manag 2013;33:11–20.
12. Wong LP. Systems thinking and leadership: how nephrologists
can transform dialysis safety to prevent infections. Clin J Am Soc
Nephrol 2018;13:655–662.
13. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating
catheter-related bloodstream infections in the intensive care unit.
Crit Care Med 2004;32:2014–2020.
14. Saint S, Olmsted RN, Fakih MG, et al. Translating health
care–associated urinary tract infection prevention research into
practice via the bladder bundle. Jt Comm J Qual Patient Saf 2009;
35:449–455.
15. Centers for Disease Control and Prevention. Reduction in central
line–associated bloodstream infections among patients in inten-
sive care units—Pennsylvania, April 2001–March 2005. MMWR
Morbid Mortal Wkly Rep 2005;54:1013–1016.
16. Trick WE, Lin MY, Cheng-Leidig R, et al. Electronic public health
registry of extensively drug-resistant organisms, Illinois, USA.
Emerg Infect Dis 2015;21:1725–1732.
17. Paulus A, Armistead N. Closing the information gap: health
information exchange in dialysis. Nephrology News and Issues July
26, 2017.
18. Morton JB, Curzake DJ, Morrill HJ, Parente DM, Gaitanis MM,
LaPlante KL. Verbal communication with providers improves
acceptance of antimicrobial stewardship interventions. Infect
Control Hosp Epidemiol 2016;37:740–742.
19. Zimring C, Denham ME, Jacob JT, et al. Evidence-based design of
healthcare facilities: Opportunities for research and practice in
infection prevention. Infect Control Hosp Epidemiol 2013;34:
514–516.
20. Rock C, Cosgrove SE, Keller SC, et al. Using a human factors
engineering approach to improve patient room cleaning and
disinfection. Infect Control Hosp Epidemiol 2016;37:1502–1506.
21. Schwartz X, Schmitz M, Safdar N, Pop-Vicas A. Adherence to
surgical hand antisepsis: Barriers and facilitators in a tertiary care
hospital. Am J Infect Control 2018 Feb 22. pii: S0196-6553(17)
31332-9. doi: 10.1016/j.ajic.2017.12.011.
22. Yanke E, Moriarity H, Carayon P, Safdar N. A qualitative, inter-
professional analysis of barriers to and facilitators of imple-
mentation of the Department of Veterans Affairs’ Clostridium
difficile prevention bundle using a human factors engineering
approach. Am J Infect Control 2018;46:276–284.
23. Yanke E, Carayon P, Safdar N. Translating evidence into practice
using a systems engineering framework for infection prevention.
Infect Control Hosp Epidemiol 2014;35:1176–1182.