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VHA National Center for Patient Safety

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Human Factors Engineering


Nurse loading a needle with patient in hospital bed in background.NCPS uses Human Factors Engineering (HFE) to improve patient safety by applying what is known about human capabilities and limitations when evaluating products or processes — a particularly significant issue when considering the sophisticated design of medical equipment.


One of the key factors when conducting an HFE review of a device or process is to determine its usability. The usability of a product or process is directly related to the sequence of actions carried out when trying to use it.

One way to think of the usability of a machine or system is to consider this sequence of actions as a “dialogue” between a tool’s user and the tool – the more intuitive the dialogue, the better. 

For example, think of the steps involved in turning on a cellular phone. In a phone built with HFE in mind, the user would simply press the “on” button to start the phone. However, as is the case with some brands of cellular phones, the “end” button must be selected to turn on the phone.

Counterintuitive designs, like the cell phone example above, can create serious problems when medical technology is in question.

The more complex and counterintuitive the sequence of actions required to run medical devices, the more likely a patient can suffer inadvertent harm.

For instance, suppose the device were a ventilator instead of a cell phone – and the function of the “on” button was equally as confusing.


Because HFE addresses specific human characteristics that are applicable to the design of a system or a device, the more “human-centered” the design, the more it can support or enhance a person’s performance.

Prior to its implementation by front-line users, a system’s performance and reliability can be improved by applying HFE principles and tools to its design, including hardware and software.

If a device has a high level of usability, it can:

  • Reduce the likelihood of causing harm to a patient.
  • Reduce the possibility of incorrect use, related to stress or to fatigue, as well as offer the user a more satisfying experience.

The device or software will also be more efficient and require less training for correct, safer use.

Learn More

  • Human Factors and Ergonomics Society*†
  • Take an HFE awareness course* online through the Federal Aviation Agency


*By clicking on these links, you will leave the Department of Veterans Affairs Web site.

VA does not endorse and is not responsible for the content of the linked Web site.