Presentation
Preventing Patient Harm - Utilizing the Human Factors Analysis and Classification System (HFACS) with Incident Cause Analysis to Better Understand and Prevent Serious Safety Events
SessionPoster Session 2
DescriptionFor the past thirteen years, MD Anderson Cancer Center has utilized the Human Factors Analysis and Classification System (HFACS) to investigate causes of Human Error through our Cause Analysis program. This Human Error Identification technique enables us to better understand the causes and contributing factors behind our Serious and Significant Safety Events. It also helps us to identify the most effective mitigation and intervention techniques to improve safety and sustainability of our process improvement solutions. In this presentation, we will discuss how our Cause Analysis program and use of HFACs have evolved, and the results and trends we have been able to observe.
Through several different iterations, we have employed a variety of cause analysis methods for our Safety Events. Coupled with the HFACS coding, we are able to identify multiple system layers of causation for immediate frontline human errors. For the past three years, we have been applying a consistent Cause & Effect mapping process, Cause Statement development, and specific coding structure. This has allowed us to identify specific trends between the HFACS tiers of Acts, Preconditions, Supervision, and Organizational Influences.
We have begun to see statistically significant relationships between HFACS categories and codes. For example, Skill-based “Autopilot” errors are most closely associated with Technology Interface Environment and Organizational Technology Resource Support, while certain Decision Errors are most closely associated with Inadequately tested or error-proofed new Standard Operating Procedures. We have also noticed statistically significant reductions in Skill-based Errors, concurrent with Institution-wide training initiatives on High Reliability Organizing tools and practices designed to reduce skill-based errors.
Identifying these associations provides concrete illustrations for the importance of user testing of technology, simulation of new processes, constant monitoring/understanding of how the current workflow evolves, and practicing good safety habits like STAR (Stop, Think, Act, and Review) moments, Stop-the-Line, and Clarifying Questions.
We’ll discuss these results and trends, and the ways we are feeding this information back to the Institutional leadership and frontline through process improvement, human factors training and communication efforts.
Through several different iterations, we have employed a variety of cause analysis methods for our Safety Events. Coupled with the HFACS coding, we are able to identify multiple system layers of causation for immediate frontline human errors. For the past three years, we have been applying a consistent Cause & Effect mapping process, Cause Statement development, and specific coding structure. This has allowed us to identify specific trends between the HFACS tiers of Acts, Preconditions, Supervision, and Organizational Influences.
We have begun to see statistically significant relationships between HFACS categories and codes. For example, Skill-based “Autopilot” errors are most closely associated with Technology Interface Environment and Organizational Technology Resource Support, while certain Decision Errors are most closely associated with Inadequately tested or error-proofed new Standard Operating Procedures. We have also noticed statistically significant reductions in Skill-based Errors, concurrent with Institution-wide training initiatives on High Reliability Organizing tools and practices designed to reduce skill-based errors.
Identifying these associations provides concrete illustrations for the importance of user testing of technology, simulation of new processes, constant monitoring/understanding of how the current workflow evolves, and practicing good safety habits like STAR (Stop, Think, Act, and Review) moments, Stop-the-Line, and Clarifying Questions.
We’ll discuss these results and trends, and the ways we are feeding this information back to the Institutional leadership and frontline through process improvement, human factors training and communication efforts.
Event Type
Poster Presentation
TimeTuesday, March 244:45pm - 6:15pm EDT
LocationRhinelander Gallery
Hospital Environments