Errors occur in all nursing settings. The current healthcare climate tends to focus on individuals as the cause of errors rather than addressing issues that may be inherently wrong with the healthcare system that predisposes the individual to make errors. Human factors engineering (HFE), which is focused on removing human factors as much as possible from errors, has the potential to greatly impact medical errors in intensive care units. Applied in other high-risk industries, HFE has been critical in understanding and preventing errors at a systems level. Knowledge concerning the role systems play in errors and improvements to medical systems using HFE is intended to empower nurses to be advocates for systems change, resulting in a safer work environment and a safer healthcare delivery system.