Color-Coding and Human Factors Engineering to Improve Patient Safety Characteristics of Paper-Based Emergency Department Clinical Documentation

Article excerpt


Objective: Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented.

Background: Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments.

Methods: During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues.

Results: Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40)

Conclusions: Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.

Key Words: Documentation, equipment design, healthcare quality improvement, human engineering, medical records


Healthcare systems face innumerable challenges to patient safety on a daily basis. Medical records, whether electronic health records (EHRs) or paper- based, represent an area where the need for confidentiality, standardization, reliability, appropriate infrastructure, information security and interoperability, ease of access, and portability can contribute to potentially dangerous conditions for a patient (Coombs, Stowasser, Reid, & Mitchell, 2009; Littlejohns, Wyatt, & Garvican, 2003; Mc- Donald, 1997; Rodriguez-Vera, Marin, Sanchez, Borrachero, & Pujol, 2002; Singh, Servoss, Kalsman, Fox, & Singh, 2004; Wears & Berg, 2005). Highly sensitive medical information may be inadvertently released or stored under an incorrect patient identifier, and proprietary health record mechanisms may improve intra-institutional operations at the expense of easy transfer of critical information across healthcare provider groups or networks. The application of human factors engineering (HFE) could mitigate some of these issues (Carayon, 2007; National Committee on Vital and Health Statistics, 2001).

One specific healthcare area for HFE investigation and intervention is the physical patient chart. Still a substantial component of medical records (as opposed to full EHRs) as reported by Jha and colleagues (2009) and Saleem et al. (2009), chart-holding binders, clipboards, folders, and related items for clinical paperwork ac- Key Words: Documentation, equipment design, healthcare quality improvement, human engineering, medical records cess and storage present an under-recognized hazard to patient safety (see Figures 1 and 2). Within this context, chart systems may benefit from HFE-based reorganization to mitigate risk to patients. Simple error-proofing of HFE interventions, such as the selective use of text fonts and sizes with prominent labeling (Wiklund, 2002), pre-implementation use-testing (Gosbee & Gosbee, 2007), cognitive and workplace walkthroughs (Khajouei, de Jongh, & Jaspers, 2009), clinical provider focus groups (Weingart et al., 2009), and the institution of fail-safe measures (Kaye & Crowley, 2000) can potentially enhance patient safety in clinical environments. …


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