Human Factor in Safe Health Care

Yury Voskanyan, Irina Shikina, Arthur Gasparyan, David Davidov

Russian Medical Academy of Continuing Professional Education of the Ministry of Health of Russia, Moscow, Russia;
Russian Institute of Health, Moscow, Russia

Cite: Voskanyan Y., Shikina I., Gasparyan A., Davidov D. Human Factor in Safe Health Care. J. Digit. Art Humanit., 3(1), 29-35.

Abstract. Over the past half century, health care has seen incredible progress related to reducing the frequency and severity of harm to patient health and life in the delivery of health care. Nevertheless, the attention of health care scientists and practitioners has begun to increase. The sources of adverse events have come to the attention of health care scientists and practitioners, such as human factor, extra-organizational causes, self-destructive behavior of the patient, which today changes the distribution of sources of adverse events. The foundation for building a strategic ladder of safe health care should have been based on the management of deviations related to illness, effective communication, patient education, and others.

Keywords: health care, patient safety, safe technology, deviance management, human factor.

  1. Buzin VN, Mikhaylova YuV, Buzina TS, Chuhrienko IYu, Shikina IB, Mikhaylov AYu. Russian healthcare through the eyes of the population: dynamics of satisfaction over the past 14 years (2006—2019): review of sociological studies. The Russian Journal of Preventive Medicine. 2020; 23(3):42–47. (In Russ.).
  2. O’Hagan, J., MacKinnon, N. J, Persaud, D., Echegaray, E. Self-Reported Medical Errors in Seven Countries: Implications for Canada // Health care Quarterly. 2009. № 12. Р. 55-61. DOI:
  3. Thiels, C. A., Lal, T. M., Nienow, J. M., Pasupathy, K. S., Blocker, R. S., Aho, J. M. Morgenthaler, T. I., Cima, R. R., Hallbeck, S., Bingener, J. Surgical never events and contributing human factors // Surgery. 2015. V. 158. № 2. P. 515-521. DOI:
  4. Makary, M. A. Daniel, M. Medical error – the third leading cause of death in the US // BMJ. 2016. № 353. Р. i2139. DOI:
  5. Voskanyan, Y., Shikina, I., Kidalov, F., Davidjv, D. Medical care safety – problems and perspectives. In book: Integrated Science in Digital Age. – Batumi, 2019. P. 291–304. doi:10.1007/978-3-030-22493-6_26
  6. Voskanyan, Y., Shikina, I., Kidalov, F., Musaeva S., Davidоv D. Latent Failures of the Individual Human Behavior as a Root Cause of Medical Errors. (2021). ICADS 2021, AISC 1352, pp. 222-234.
  7. Zegers M., Bruijne M.C., Wagner C. et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual. Saf. Health Care. 2009;18:297–302.
  8. Donaldson L., Ricciardi W., Sheridan S., Tartaglia R. Textbook of Patient Safety and Clinical Risk Management. Springer Nature.
  9. Voskanyan, Y., Shikina, I., Kidalov, F., Davidоv D., Abrosimova T. Risk management in the healthcare safety management system. Journal of Digital Science 2021; 3(1),
  10. Leape L.L. Error in medicine. JAMA. 1994; 272:1851–1857. https://doi:10.1001/jama.1994.03520230061039
  11. Kohn L.T., Corrigan J., Donaldson M.S. To err human: building a safer health system. National Acade Press, Washington, DC, 2000.
  12. Reason J. Safety in the operating theatre – Part 2: Human error and organisational failure. Qual. Saf. Health Care. 2005;14:56–61.
  13. St. Pierre M., Hofinger G., Buerschaper C. Crisis Management in Acute Care Settings Human Factors and Team Psychology in a High Stakes Environment. Springer-Verlag Berlin Heidelberg 2008.
  14. Beuzekom, M., Boer, F., Akerboom, S., Hudson, P. Patient safety in the operating room: an intervention study on latent risk factors. Surgery. 2012. № 12. Р. 1-11. DOI:
  15. Roehr B. US has highest dissatisfaction with health care BMJ. 2007; 335(7627): 956.
  16. Hero J.O., Blendon R.J., Zaslavsky A.M., Campbel A.L. Understanding What Makes Americans Dissatisfied With Their Health Care System: An International Comparison. Health Affairs. 2016; 35(3): 502-509.
  17. Hoffman J.R., Kanzaria H.K. Intolerance of error and culture of blame drive medical excess. BMJ.- 2014;349:g5702.  DOI:
  18. Machen S., Jani Y., Turner S., Marshall M., Fulop N.J. The role of organizational and professional cultures in medication safety: a scoping review of the literature. Int. J. Qual. Health Care, 2019, 31(10):146–157
  19. Silva L.C., Caldas C.P., Fassarella C.S., Souza P.S. Effect of the organizational culture for patient safety in the hospital setting: A systematic review. Aquichan. 2021; 21(2):e2123.
  20. Roitberg, G. E., Kondratova, N. V. Medical organization according to international quality standards: a practical guide for implementation. – М., 2018. – 152 с.
  21. Kapur, N., Parand, A., Soukup, T., Reader, T., Sevdalis, N. Aviation and health care: a comparative review with implications for patient safety // Journal of the Royal Society of Medicine Open. 2016 Jan. 7:2054270415616548. DOI:

Published online 29.06.2022