期刊
CLINICAL MEDICINE
卷 22, 期 5, 页码 423-433出版社
ROY COLL PHYS LONDON EDITORIAL OFFICE
DOI: 10.7861/clinmed.2022-0042
关键词
patient safety; incident investigations; Human Factors Analysis and Classification System; HFACS; adverse event
资金
- Health Foundation's Improvement Science Fellowship
- Health Foundation [RG88620]
- National Institute for Health and Care Research (NIHR) [NF-SI-0617-10026]
This study used the HFACS framework to analyze contributory factors in serious incident investigation reports. It found that "unsafe actions" were the most commonly identified factors, followed by "preconditions to unsafe acts" which included miscommunication and environmental factors, as well as supervisory factors and organizational factors.
Background Serious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study aimed to use the Human Factors Analysis and Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports.Methods We performed a content analysis of 126 investigation reports from a multi-site NHS trust. We used a HFACS-based framework that was modified through inductive analysis of the data.Results Using the modified HFACS framework, 'unsafe actions' were the most commonly identified hierarchical level of contributory factors in investigation reports, which were identified 282 times across 99 (79%) incidents. 'Preconditions to unsafe acts' (identified 223 times in 91 (72%) incidents) included miscommunication and environmental factors. Supervisory factors were identified 73 times across 40 (31%) incidents, and organisational factors 115 times across 59 (47%) incidents. We identified 'extra-organisational factors' as a new HFACS level, though it was infrequently described.Conclusions Analysis of SI investigation reports using a modified HFACS framework allows important insights into what investigators view as contributory factors. We found an emphasis on human error but little engagement with why it occurs. Better investigations will require independence and professionalisation of investigators, human factors expertise, and a systems approach. Introduction Over cause annually.1 their adverse notified a the factors events cause framework what causes healthcare by sources establish to various recommendations on reactions care).7-9 investigators areas. of
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