Human factors and a systems approach can offer unique insight into the redesign process of medical charts to enhance usability. This paper describes a mixed method approach utilising numerous HF tools and theories to support the redesign process for an inpatient anticoagulant medication chart. The system factors and error-producing conditions associated with the use of this chart were identified through a qualitative analysis, using the SEIPS 2.0 model, of 65 reported incidents associated with the use of this chart. To better understand the role of this document at a task level, the task ‘first time prescription of anticoagulant medication’ was analysed in more detail using Hierarchical Task Analysis and the Systematic Human Error Reduction Approach. The incident report data was then also mapped onto the HTA and SHERPA of the task. Based on studies that applied heuristic analyses and a human factors perspective to chart design and evaluation, key design characteristics were compiled that were used to evaluate the chart. The results from these three different analyses were used to compile recommendations for the next design iteration of this chart.
