A hospice patient received a lethal dose of an IV narcotic medication.

NAHQ patient safety guidance emphasizes human factors engineering, which examines how system design influences human behavior. In this case, the tubing fit easily into the pump despite being incompatible, creating a design-induced error.

There is no indication of incompetence, lack of information, or equipment malfunction. The error resulted from system and design flaws that made unsafe action easy, which defines a human factors issue. Therefore, Option D is correct.