A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting

Abstract

Various human factors classification frameworks have been used to identified causal factors for clinical adverse events. A systematic review was conducted to identify human factors classification frameworks that identified the causal factors (including human error) of adverse events in a hospital setting. Six electronic databases were searched, identifying 1997 articles and 38 of these met inclusion criteria. Most studies included causal contributing factors as well as error and error type, but the nature of coding varied considerably between studies. The ability of human factors classification frameworks to provide information on specific causal factors for an adverse event enables the focus of preventive attention on areas where improvements are most needed. This review highlighted some areas needing considerable improvement in order to meet this need, including better definition of terms, more emphasis on assessing reliability of coding and greater sophistication in analysis of results of the classification. Practitioner Summary: Human factors classification frameworks can be used to identify causal factors of clinical adverse events. However, this review suggests that existing frameworks are diverse, limited in their identification of the context of human error and have poor reliability when used by different individuals.

Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital

“…While the human factors taxonomies that have been used in health care are diverse in their structure, what is common across the literature is that human factors, particularly human error, plays a leading role in clinical incidents (Mitchell et al, 2014). Errors, defined as 'the failure of a planned action to proceed as planned' (US Institute of Medicine, (2000)), have been retrospectively analysed in the health care setting, but studies differ in the way that medical errors are classified.…”

Modern principles of management of patient safety (systematic review)

“…Латентные угрозы существуют на уровнях персонала, пациента и среды. На каждом из этих уровней выделяют две группы латентных угроз: глобальные латентные угрозы (присутствуют независимо от места оказания медицинской помощи и ее профиля) и специфические латентные угрозы (обусловлены спецификой места оказания медицинской помощи и ее профилем) [9][10][11][12]. Модель швейцарского сыра [7,8,10,13,20].…”

The development of the Schema-Action-World (SAW) taxonomy for understanding decision making in aeronautical critical incidents

“…So whilst the SAW taxonomy is datadriven, it was still developed within the confines of the PCM and the data had already been deductively classified based on the high level categories of this model. Mitchell et al (2014) conducted an extensive review of human factors taxonomies for use in a medical setting and found that a third of the taxonomies they reviewed did not have a theoretical model underpinning their development and that almost all of the taxonomies either focused on cognitive or contextual factors, rarely both. The SAW taxonomy was underpinned by a theory that considers both the contextual and cognitive factors of behaviour.…”