Using HFACS-Healthcare to Identify Systemic Vulnerabilities During Surgery.

Area of Science:

• Healthcare Quality and Safety
• Human Factors Engineering
• Patient Safety Research

Background:

• Surgical near miss events are critical indicators of potential patient harm.
• Traditional incident reporting often focuses on frequency rather than root cause analysis.
• Effective analysis of near misses is essential for proactive patient safety improvements.

Purpose of the Study:

• To classify surgical near miss events using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare).
• To identify the underlying causal factors contributing to surgical near misses.
• To demonstrate the value of human factors analysis in improving patient safety.

Main Methods:

• Surgical near miss events were collected from a hospital's event reporting system over one year.
• Two analysts categorized events and identified causal factors using the HFACS-Healthcare framework.
• A total of 592 events were analyzed, identifying 726 causal factors.

Main Results:

• The majority of identified issues were preconditions for unsafe acts (60.00%).
• Unsafe acts constituted the second most frequent category (35.39%).
• Organizational influences (3.72%) and supervisory factors (0.82%) were less common.

Conclusions:

• Analyzing near misses through the lens of human factors provides deeper insights than traditional trending.
• Identifying preconditions for unsafe acts offers significant opportunities for process improvement.
• This methodology supports the development of targeted interventions to enhance patient safety and reduce event reoccurrence.