Integrating Human Factors into RCA^2: A Qualitative Case Study
Event Type
Oral Presentations
TimeWednesday, April 142:00pm - 2:20pm EDT
LocationPatient Safety Research and Initiatives

The National Patient Safety Foundation’s RCA^2 guidelines offer fundamental improvements to root cause analysis (RCA) investigations of patient harm events. These improvements, however, center mainly on changes to the process and procedures for conducting an RCA investigation. The tools contained in the document still only support traditional RCA activities, such as performing risk assessments of events, developing timelines, and rating the strength of safety recommendations. Currently, RCA^2 guidelines stop short of providing a foundational set of robust human factors tools and methods that enable users to (a) reliably perform a thorough human factors analysis of patient harm events and (b) systematically generate effective human factors interventions to improve safety.


To address this critical gap, our team systematically integrated a complement of well‐established human factors methods and tools into the RCA^2 process. Our approach is grounded in the Human Factors Analysis and Classification System (HFACS), as well as the Human Factors Intervention Matrix (HFIX) and FACES methodologies. [1-4] These tools have also been shown to facilitate the process of identifying and correcting the underlying systems issues associated with patient safety events. [5-9] When combined with RCA^2, this complement of methods and tools creates a robust human factors process, called HFACS‐RCA2, that is specifically designed to identify and prevent human factors and systems issues associated with patient harm events. To date, however, there is no single source that describes each of these human factors methods and tools (I.e., HFACS, HFIX, and FACES), or the process by which they can be effectively integrated into the RCA^2 approach. Furthermore, little has been published regarding health care systems’ experiences associated with implementing HFACS‐RCA2.


Our research team conducted an 18‐month implementation study of HFACS‐RCA2 within a large, Midwest academic health center to evaluate its feasibility and identify any organizational variables that might serve to either facilitate or hinder implementation success. The results of our qualitative analyses of structured interviews conducted with key stakeholders (n = 12) involved in this process, including risk managers, quality improvement specialists, patient safety managers, and senior leadership are presented here. Our research yielded positive findings associated with HFACS‐RCA^2 outcomes (I.e., types of causal factors identified, and corrective actions generated), and identified various barriers and facilitators/strategies to implementation success. In addition, we will discuss some unintended, albeit positive, consequences that also emerged as a result of HFACS‐RCA^2 adoption (e.g., changes in culture).

Overview of Presentation

Our research describes each of these tools and illustrates how they can be integrated into RCA^2 to create a robust human factors RCA process called HFACS‐RCA^2. We also present qualitative results from this 18‐month implementation study within a large academic health center. The results of this study demonstrated that HFACS‐RCA2 can (1) foster a more comprehensive, human factors analysis of serious patient harm events and (2) facilitate the identification of broader system interventions. Following the HFACS‐RCA^2 implementation, RCA team members (risk managers and quality improvement advisors) also experienced greater satisfaction in their work, leadership gained more trust in RCA findings and recommendations, and the transparency of the RCA process increased. We also highlight some effective strategies for overcoming implementation barriers, including changes in roles, responsibilities, and workload.

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