Close

Presentation

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
DescriptionTopic

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.

Application

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.

Background

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.

1) Wiegmann DA, Shappell SA. A human error approach to aviation accident analysis: The human factors analysis and classification system. Routledge; 2017 Dec 22;1-165

2) Shappell S, Wiegmann D. A methodology for assessing safety programs targeting human error in aviation. The International Journal of Aviation Psychology. 2009 Jun 26;19(3):252-69.

3) Wiegmann, DA & Shappell, SA. Human error analysis of commercial aviation accidents: application of the Human Factors Analysis and Classification system (HFACS). Aviation, Space, & Environmental Medicine, 2001; 72(11): 1006-1016.

4) Shappell S, Detwiler C, Holcomb K, Hackworth C, Boquet A, Wiegmann DA. Human error and commercial aviation accidents: an analysis using the human factors analysis and classification system. Human factors. 2007 Apr;49(2):227-42.

5) Berry KA, Stringfellow PF, Shappell SA. Examining error pathways: an analysis of contributing factors using HFACS in non-aviation industries. In Proceedings of the human factors and ergonomics society annual meeting 2010 Sep (Vol. 54, No. 21, pp. 1900-1904). Sage CA: Los Angeles, CA: SAGE Publications.

6) Diller T, Helmrich G, Dunning S, Cox S, Buchanan A, Shappell S. The human factors analysis classification system (HFACS) applied to health care. American journal of medical Quality. 2014 May;29(3):181-90.

7) Cohen TN, Francis SE, Wiegmann DA, Shappell SA, Gewertz BL. Using HFACS-healthcare to identify systemic vulnerabilities during surgery. American Journal of Medical Quality. 2018 Nov;33(6):614-22.

8) Litzinger TL, Cohen TN, Cabrera JS, Captain KA, Fabian MA, Miles SG, Shappell SA, Boquet AJ. A Data-Driven Approach to Team Training for Nurses in a Level II Trauma Center. Journal of Trauma Nursing| JTN. 2019 May 1;26(3):134-40.

9) Spiess BD, Rotruck J, McCarthy H, Suarez-Wincosci O, Kasirajan V, Wahr J, Shappell S. Human factors analysis of a near-miss event: oxygen supply failure during cardiopulmonary bypass. Journal of cardiothoracic and vascular anesthesia. 2015 Feb;29(1):204.