What We Do

The National Center for Human Factors in Healthcare brings together a diverse set of human factors and clinical experts to improve quality, efficiency, reliability, and safety in healthcare. A part of the MedStar Institute for Innovation (MI2) and the MedStar Health Research Institute (MHRI), the Center’s home and “research lab” is MedStar Health, a $6.1B not-for-profit healthcare organization. 

Our unique, patient-first philosophy provides:

  • Access: Direct access to 10 hospitals and more than 280 diversified healthcare organizations in MedStar Health’s clinical
    environments, as well as frontline clinicians and patients in a wide array of clinical settings.
  • Expertise: Multi-disciplinary expertise including human factors engineers, clinicians, computer scientists, informatics experts and environmental designers, as well faculty partners that prioritize user needs.
  • Scientific Rigor: Nationally-recognized academic excellence that is operationally focused—MedStar Health is a leading medical institution and home to one of the largest graduate medical education programs, ground-breaking new technology and a unique environment to spur innovation.

Learn more about what we do:

Research  We leverage theory to conduct applied research that addresses critical safety problems and contributes to the generation and dissemination of knowledge in the healthcare industry.

Education and Outreach  We offer dedicated training and mentoring to the next generation of human factors specialists, domestically and globally.

Usability Services  We contribute to the development of products and processes that are user-centered through understanding human capabilities and limitations.

Consulting Services  We provide a systems approach that assesses multiple factors and promotes a proactive path to safety.


For Clinicians

Our focus is on giving learners practical skills to integrate human factors principles into daily activities, rather than becoming an expert in human factors.

Currently we offer both half-day and full-day education sessions. We also offer a course for medical students through Georgetown University School of Medicine, designed to specifically to understand and apply human factors concepts throughout medical training.

For Human Factor Experts

As a human factors expert, understanding how human factors principles apply within different environments is imperative.

Healthcare is a complex and dynamic field with unique opportunities for human factors experts. For our researchers’ areas of interest and expertise, please click here.

Student Opportunities

We also offer a limited number of research internships each year to qualified students. We regularly work with psychology, engineering and medical students on different research projects.

Conferences, Workshops, and Speaking Engagements

The NCHFH hosts training opportunities throughout the year targeted to a wide range of healthcare professionals, from frontline staff to executives as well as to human factors professionals interested in healthcare.


We also offer tailored education opportunities in half and full day as well as multi-day workshops. If you are interested in learning more, please contact us!

For more information about education, please contact Terry Fairbanks at [email protected].

Consulting Services

Whether you are a healthcare organization looking for an objective hazard analysis, a medical device manufacturer in need of an FDA 510(k) human factors evaluation, or a professional organization simply looking for a human factors consult, our team has the expertise to assist. We are knowledgeable in methods such as conducting task analyses and work flow assessments, and also have specialized expertise in several healthcare relevant areas. Let us help you meet your safety goals.

Event Reviews and Hazard Analyses

Let our team of human factors engineers and clinical patient safety experts work to complement the services of your organization’s event review team.

We apply scientific principles from the safety engineering disciplines to identify system-based contributing factors, and to produce recommendations for sustainable, effective solutions. During our examination, we apply a systems engineering approach to consider the organizational, medical device, work process, people, and environmental factors that led to the event. Strict confidentiality of data and reports is always our priority.


The Usability division at the National Center for Human Factors in Healthcare provides customized usability consultations and testing across the product development process.

View the usability page.

For more information about consulting, please contact Lawrence Wolpert at [email protected].

Usability Services

We provide customized usability consultations and testing throughout the product development process. Through MedStar Health, our usability experts have direct access to healthcare domain specialists and end users in a wide array of clinical settings and use environments. From directed customer needs assessments to complex clinical simulations, we connect developers with clinical subject matter experts to optimize feedback specific for your product. Our services promote safe, marketable and effective products that will be market-ready faster.

Medical Device Usability Evaluation

We analyze usability through tailored evaluations for your unique product and development needs.

From directed customer needs assessments to complex clinical simulations, Usability Services connects developers with clinical subject matter experts to maximize feedback specific for your product.

Guidance for FDA Regulatory Submission

Is your product on track for regulatory approval?

We conduct all necessary evaluations to meet regulations such as:

  • FDA Human Factors Guidance for 510(k) Pre-Market Approval
  • ANSI/AAMI HE75 Human Factors Engineering – Design of Medical Devices
  • ISO 62366 – Application of Usability Engineering to Medical Devices
  • ISO 9241 – Ergonomics of Human System Interaction
  • Other relevant medical application standards such as MIL, W3C, etc.

Customized Approach at All Stages of Development

We can help at any stage of the product development lifecycle.

Our team performs formative and summative testing for both pre-market and post-market activities. Getting started with early-stage formative tests can save you time and money before final prototypes have been created, and we also plan and coordinate summative tests to provide the necessary documentation for regulatory approval.

Examples of our core competencies throughout the product lifecycle include:

Types of Products We Evaluate

Our usability experts have the experience and expertise to evaluate a wide range of medical devices and products.

Our capabilities include evaluation of:

  • Medical Devices in All Healthcare Domains
  • Medical Device Accessories
  • Websites and Mobile Applications
  • Health Information Technology 
  • Documentation and Training
  • Anthropometrics and Accessibility
  • Signage and Labeling
  • Instructions for Use

Testing Environments for All Needs

Partnering with Usability Services gives you access to a variety of settings and users to aid in the development of your products.

Our staff and collaborative partners have a wide range of expertise across multiple settings, including: static laboratory (heuristic/expert reviews), usability laboratory, and in-situ testing (in the actual use environment). In addition, our SiTEL Simulation center gives you access to a rich array of simulation environments including high fidelity patient-based healthcare simulators, IT prototype development, “serious game-based” simulation, and others. We also offer an unparalleled “actual use environment” laboratory within MedStar Health.


Guest column series on Med Device Online by Natalie Abts

How To Effectively Evaluate Instructional Materials and Labeling Before Development Is Complete

For more information about usability, please contact Lawrence Wolpert at [email protected].


The MedStar Health National Center for Human Factors in Healthcare research team focuses on leveraging theory to conduct applied research that addresses critical safety problems in health care. We are the nation's innovative leader in human factors and healthcare research given our unparalleled access to a 10-hospital healthcare system, diverse range of clinical expertise, and expertise in human factors, applied cognition, and safety engineering. In addition to reviewing the key information below about our research work, visit our Publications and Videos pages for more resources.


We have expertise rigorously applying a variety of methods, including: 

General methods are used to answer specific questions about human behavior in complex environments. 

  • Focus groups and interviews
  • Time motion studies
  • Ethnography/Observations
  • Eye tracking
  • Physiological sensors
  • Data mining

Modeling focuses on developing quantitative techniques to understand human behavior and interactions with their environment. 

  • Machine learning & statistical models
  • Natural language processing 
  • Mental models
  • Predictive analytics

Usability methods focus on identifying user needs, designing and developing for these needs, and assessing to ensure they are met. 

  • Heuristic analysis
  • Task analysis
  • User-centered design
  • Usability testing 

Safety and risk assessment methods focus on identifying potential points of failure.

  • Failure mode effects analysis
  • Human error identification
  • Incident investigation
  • Space syntax

Key Research Grants and Contracts

Following is a summary of some of our largest and most recent research efforts. In particular, our MedStar Health National Center for Human Factors in Healthcare team is proud to have four active multi-year Research Project Grant (R01) awards from the U.S. Department of Health and Human Services, which are considered to be among the most prestigious grant mechanisms. Our top leaders are the principal investigators (PIs) on three Agency for Healthcare Research and Quality-funded R01s that focus on improving the safety of electronic medication administration records, usability and safety guidelines for health information technology, and technology to support emergency department communication, as well as a National Institutes of Health (National Library of Medicine)-funded R01 on developing effective clinical decision support.

For more information about our research work or to explore possible collaboration opportunities, please contact us at [email protected]

Cognitive Engineering for Complex Decision Making & Problem Solving in Acute Care (R01)

Agency for Healthcare Research and Quality
MedStar Human Factors Center PI: Zach Hettinger, MD

Purpose: This research applies human factors engineering—and, specifically, cognitive systems engineering methods—to examine the nature of cognition, tasks, and work in the context of the emergency department. Our results will help inform the design, development, and evaluation of future information technology (IT) innovations, thus providing a methodological example and “proof-of-concept” for translating cognitive engineering analysis into design.

Approach/Methods: A combination of interviews, observations, screen capture recordings, and retrospective data reviews are being conducted to perform a cognitive engineering analysis of emergency medicine and iteratively develop design guidance and prototypes addressing key challenges identified. This data will be analyzed primarily using work domain analysis and abstraction hierarchy frameworks. The developed prototypes will be evaluated using user-centered evaluation methods in realistic simulated tasks set in a clinical simulation center. Multiple usability tests will be performed for each of the many prototypes developed and optimized iteratively.

Signaling Sepsis: Developing a Framework to Optimize Alert Design (R01)

National Library of Medicine
MedStar Human Factors Center PI: Kristen Miller, DrPH

Purpose: The current structure of electronic health record (EHR) systems provides clinicians access to raw patient data without imputation of its significance or utilization of validated illness-severity scoring systems. Focusing on sepsis detection and treatment, this research develops and tests multiple enhanced visual display models that integrate patient data into validated sepsis staging scores with the primary objective of informing the development of future real-time clinical decision support (CDS) tools.

Approach/Methods: Simulated EHR environments were built using clinical scenarios based on real patient data. CDS alerts were developed for both the Predisposition, Infection, Response, Organ Dysfunction (PIRO) and quick Sepsis-Related Organ Failure Assessment (qSOFA) scores for use in usability evaluations. One-on-one usability sessions are conducted to evaluate participants’ thought processes, expectations, observations, challenges, and successes while using the simulated EHR and CDS alert designs. Usability is measured relative to users’ performance on a given set of tasks targeting: (1) performance-related measures including success rate (correctness of alert interpretation, appropriate response); and (2) preference-related measures including participants’ subjective satisfaction and cognitive load.

Read more in the related press release.

Developing Evidence-Based User-Centered Design and Implementation Guidelines to Improve Health Information Technology Usability (R01)

Agency for Healthcare Research and Quality
MedStar Human Factors Center PI: Raj Ratwani, PhD

Purpose: To improve the usability and safety of health information technology (HIT) we will analyze patient safety event reports to determine the impact of HIT. From the HIT-related events we will determine how to improve current design methods, policies, and testing procedures. This knowledge will serve to inform vendor and provider practice, as well as policymaker decisions.

Approach/Methods: Natural language processing will be used to analyze millions of patient safety event reports. Expert consensus will be used to create guidelines for vendors, providers, and policymakers.

Improving Patient Safety and Clinician Cognitive Support Through EMAR Redesign (R01)

Agency for Healthcare Research and Quality
MedStar Human Factors Center PI: Raj Ratwani, PhD

Purpose: The objective of the research is to reduce the patient safety hazards associated with electronic medication administration records (eMARs) by: (1) understanding current usability and safety gaps; and (2) creating design and development documents, wireframes, and prototypes to serve as the foundation for future eMARs that will eliminate these gaps. In particular, we focus on communication and information flow challenges between nurses, pharmacists, and physicians during medication administration and use of the eMAR.

Approach/Methods: Machine learning will be used to identify safety hazards from patient safety event reports. In addition, observations will be conducted to capture frontline clinician experiences.

Context is Critical: Understanding When and Why EHR-Related Safety Hazards Happen (R21)

Agency for Healthcare Research and Quality
MedStar Human Factors Center PI: Zach Hettinger, MD

Purpose: This study outlines a novel approach to retrospectively identify and analyze electronic health record (EHR)-facilitated errors based on the concept of a flight recorder or black box. The purpose of this study is to understand the context of errors by combining EHR safety event data queries, systemwide video capture of EHR interactions, and human factors heuristics analysis. The significance of this acceptance is the wide dissemination of this novel framework to detect, capture, review, and document health information technology errors.

Approach/Methods: Likely EHR-facilitated error patterns were selected by subject matter experts in the field of medicine, usability, human factors, and safety science. The research team then actively searched for discrete occurrences of these common safety error patterns within the EHR. Results were filtered down to instances of potential errors, and videos of these errors occurring were subsequently abstracted and reviewed. This process will be utilized to determine the specific design elements of the EHR system that facilitates these errors, and to subsequently create data-driven design guidelines based on the most common error causing elements.