Abstract
Human factors have been identified as the most frequent cause of and contributory factor to sentinel events. Many human factor errors are preventable, and neonatal nurses are instrumental at the point of care in working with system leaders to identify various problems and potentially safe practices that can be hardwired into daily practice. This article defines human factors that often occur in daily processes of care in many neonatal intensive care units (NICU) and specific evidence-based strategies to implement to reduce preventable human errors. Human factor evidence from other high-risk industries is relevant to healthcare and can be applied to the complex adaptive environment of the NICU. Nurses need to be mindful of their complex environment and to have a basic understanding of the role of human factors principles.