This review discusses the important role ergonomic and human factors should play in ensuring safe anesthetic care, drawing on literature from non-health care settings. The authors begin by discussing errors in anesthesia and the opportunities created for such errors by the inevitable nature of the job. They continue by presenting a framework for the contributing factors, which include the work environment (eg, noise, lighting, temperature), the human component (eg, team factors, fatigue, workload), and the equipment and system component (eg, alarms, automation). The authors advocate for greater attention to these contributing factors and further study based on the experiences of other high-risk, error-prone industries.