A nurse can know exactly how to give a medicine safely and still be more likely to make a mistake if they are repeatedly interrupted, given confusing information or forced to search several computer systems for the details they need.
For patients, the consequences can be serious. Research has linked problems during clinical handovers with risks to safe care, while interruptions during medication administration have been associated with errors.
When something goes wrong in healthcare, attention often falls on the person who made the mistake. But patient safety also depends on the conditions in which doctors, nurses and other healthcare professionals are working. Is important information easy to find? Does technology help them do their job or make it harder? Can they concentrate on a task without unnecessary interruptions?
Understanding how these conditions affect safety is the focus of Human Factors and Ergonomics, usually shortened to HFE. HFE examines how people interact with the systems, technology, tasks and environments around them. In healthcare, it can help identify features of working conditions that support safe care or make mistakes more likely.
The principle is simple. Human attention, memory and energy have limits, so healthcare should be designed with those limits in mind. Expecting staff simply to concentrate harder cannot compensate for a confusing computer system, missing information or a badly organised process.
A recent NHS investigation shows the potential consequences. In 2025, the Health Services Safety Investigations Body (HSSIB) examined the case of a man with type 2 diabetes who went without insulin for 15 days after leaving hospital. The investigation identified problems with communication and the transfer of information between hospital and community services. It examined the wider circumstances surrounding his care, including discharge processes, electronic systems and how responsibility for his insulin support was communicated.
Yet nurses are not consistently introduced to these ideas during their undergraduate training. A systematic review of undergraduate healthcare education found that human factors and patient safety were not consistently built into courses, while a survey of nursing schools in England found considerable variation in how the subjects were taught.
That means some nurses can enter clinical practice without having been taught a structured way to recognise when the system around them is making their job less safe.
Poorly designed electronic records offer one example. Research has found that they can increase nurses’ workload and encourage workarounds, where staff find alternative ways of completing a task when the official system does not fit well with clinical work.
Imagine that important medication information is difficult to find. An experienced nurse may know where to look or which colleague to ask. The immediate problem disappears, but the flaw in the system remains. A newly qualified or temporary member of staff may struggle to find the same information during a busy shift.
Teaching HFE during nursing degrees could help students recognise problems like these before they begin working independently. It could also change how they think about mistakes.
Professional accountability remains essential. But patient-safety research shows why asking only who made an error can give an incomplete picture of why it happened. If a nurse gives the wrong medication after being repeatedly interrupted, their actions need to be examined alongside the circumstances in which the error occurred. Studies have found an association between interruptions during medication administration and increased error risk.
Looking at those wider conditions can reveal changes that reduce the chances of the same problem happening again.
Nurses are particularly well placed to notice weaknesses because they work across many parts of patient care. They use electronic records and medication systems, pass information between teams and monitor changes in patients’ conditions. Human factors approaches can help turn that frontline experience into ways of identifying and improving problems in healthcare systems.
This is especially relevant as healthcare becomes increasingly digital. In May 2026, HSSIB found that there were no core national patient-safety standards governing the design or procurement of electronic prescribing and medicines-administration systems in NHS acute hospitals. It found variation between systems and trusts that could create difficulties for staff prescribing and administering medicines.
A separate 2025 HSSIB review found that problems with electronic patient records could contribute to care being missed, delayed or incorrect. Research into human factors and health information technology has also shown how the design and usability of technology can influence its safety in real healthcare settings.
Nursing students therefore need more than instructions on how to operate new technology. They also need to understand how its design can increase workload, make information harder to find or create opportunities for error.
HFE does not necessarily need to be taught as a separate subject. Its principles could be included in teaching nurses already receive. Medication training could examine how interruptions contribute to errors. Communication teaching could use research on clinical handovers to explore why important information can be lost. Students could also consider how staffing levels affect the conditions in which care is delivered.
Postgraduate education and continuing professional development can deepen that knowledge later. But nurses should encounter the basic principles before they begin practising independently.
Patients rely on nurses making good decisions in healthcare systems that are often busy and complicated. Newly qualified nurses should not have to learn through trial and error how to compensate for systems that make safe care harder. Teaching them how to recognise those risks and contribute to reducing them could help protect patients from the start of their careers.
Anna Chatzi receives funding from Research Ireland (RI), Health Research Board (HRB) and the Health Service Executive (HSE).
