ABSTRACT
Ergonomics and its fraternal twin human factors are no strangers to the topic of medical error. In
1960, a nursing student published a two-part article coauthored by her mentor Alphonse Chapanis
(Safren & Chapanis, 1960a, b) that reported medication mishap findings analogous to those of the
Harvard Medical Practice Study (HMPS) published 36 yr later (Leape et al., 1991). A book Human
Factors in Health Care (Pickett & Triggs) was published in 1975. In 1978, an article appeared that
addressed human factors issues in anesthesia gas machines (Cooper, Newbower, Long, & McPeek,
1978). The book Human Error in Medicine (Bogner, 1994) presented a systems approach to
medical error.
