Implementing a human factors approach to RCA² : Tools, processes and strategies

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Human Factors Engineering

Background:

• Traditional Root Cause Analysis and Action (RCA²) guidelines lack robust methods for human factors analysis of patient harm.
• There is a need for systems-level interventions to address patient safety events effectively.

Purpose of the Study:

• To integrate human factors tools into the RCA² process to create a more comprehensive approach.
• To develop and evaluate a Human Factors Analysis and Classification System integrated RCA² (HFACS-RCA²) process.

Main Methods:

• Integration of the Human Factors Analysis and Classification System (HFACS), Human Factors Intervention Matrix (HFIX), and FACES decision tool into RCA².
• Qualitative results from an 18-month implementation study at a large academic health center.

Main Results:

• HFACS-RCA² fosters a more comprehensive, human factors analysis of serious patient harm events.
• Broader system interventions were identified, leading to increased RCA team satisfaction, leadership trust, and process transparency.

Conclusions:

• The HFACS-RCA² process offers a robust human factors approach to patient safety analysis.
• Implementation strategies for overcoming barriers, including role and workload adjustments, are crucial for success.