ArticleApplying human factors methods to the investigation and analysis of clinical adverse events
Introduction
The systematic analysis of accidents and serious incidents is a fundamental feature of most industrial safety programmes and human factors methods of incident analysis are used to generate information about many aspects of system performance. Approaches to safety in medicine are very different from those in industry, and until recently there have been few easy points of entry for human factors specialists, though the field is developing rapidly in healthcare and the case for human factors approaches is becoming clearer. To orient readers from non-medical contexts we briefly introduce medical approaches to quality and safety before turning to the application of human factors methods to an obstetric incident.
Section snippets
Improving the quality of care in medicine
Formal studies of quality of care in healthcare can be traced back to the early part of the century (Groves, 1908) but the last 20 years have seen a massive increase in formal quality initiatives and the volume of studies published. Taylor (1996) identified 25 different approaches to safety and quality currently being used in the British National Health Service. For example, clinical audit is a systematic review of some aspect of the process or outcome of healthcare, with the aim of intervening
The epidemiology of adverse events in medicine
In spite of this increased attention to quality, errors and adverse patient outcomes are still frequent (Leape, 1994) and the risk of iatrogenic injury to patients in acute hospitals remains remarkably stable. Studies in California in 1974 (Mills, 1995), New York in 1984 (Brennan et al., 1991), and Colorado and Utah in 1992 (Vincent, 1997) have all found that adverse events, occasions in which patients are unintentionally harmed by treatment, occurred in almost 4% of admissions. For 70% of
The development of clinical risk management
Clinical risk management (CRM) offers a possible avenue of approach for human factors specialists, as it is an approach to quality and safety which specifically targets adverse events and is modelled on risk management approaches in other settings. CRM was initially considered a means of reducing litigation, a topic which attracts considerable attention in the health service (Vincent and Bark, 1995). Early clinical risk management strategies, principally in the USA, focused on managing
The development of human factors approaches in medicine
The assessment of accidents in large-scale socio-technical systems has acquired a high profile in industry, after such disasters as Bhopal, Chernobyl and Piper Alpha. The human factors community has developed a variety of methods of analysis, which have begun to be adapted for use in medical contexts (Bognor, 1994). Reason (1993) (p.1) has suggested that the results of such investigations “have clearly shown that medical mishaps share many important causal similarities with the breakdown of
Reason’s organisational accident causation model
Reason’s (Reason (1993), Reason (1995) Organisational Accident Causation Model was originally developed for use in complex industrial systems as a mechanism for understanding the relationships between the theoretical components of organisational accidents, thus helping to identify effective methods of accident prevention. This human factors model has already proved useful in the context of medical accidents and incidents (Eagle et al., 1992, Stanhope et al., 1997) and is used to guide our
Method
The following obstetric case is one of a number we have examined as part of a research programme which aims to develop a structured and systematic method of investigating adverse and near-miss outcomes in medicine.
A list of people involved in the case including both midwifery and obstetric staff was compiled. Six people consisting of two junior doctors, the admitting midwife on labour ward (LW) (midwife A), the antenatal ward (ANW) midwife (midwife B), the postnatal ward (PNW) midwife (midwife
Interview structure
The length of the interview varied for each person, depending on the time they had available and on the extent of their involvement in the case. None took longer than 30 min. All the interviewees were willing to talk about the case, and some commented that the opportunity to discuss it enabled them to voice concerns and anxieties about the unit that they sometimes felt reluctant to raise with their colleagues. There were three consecutive stages to the interview:
- 1.
Each member of staff was asked
Case history
To illustrate Reason’s model we will briefly describe a case involving a post-partum haemorrhage of 1200 ml. The essentials of the case are presented in the following boxFig. 1. It is based on an actual case, although a number of details have been changed to protect the anonymity of those involved.
Analysis of the case
Table 1 shows some of the active failures detected in this case; the current conditions of work which triggered the active failures; latent failures, the conditions and decisions made by management which lie dormant until activated by antecedent conditions.
There were a number of communication failures between midwives on different wards and between midwives and doctors in general. Workload and time pressure were also identified as a possible cause of this incident. However, an absence of clear
Positive features of the case
The analysis might suggest that the unit is riddled with unresolved problems. This is not so, and there were several features which highlighted good aspects of the unit’s performance.
- 1.
Midwife ‘A’ knew Jenny had had a quick delivery previously and sent her to the ANW when her contractions reduced rather than let her go straight home. This decision was to ensure Jenny had midwifery attention available if she did go into labour over the next few hours.
- 2.
Once the post-partum haemorrhage (PPH) had been
Potential error reduction strategies
It is important to emphasise that error reduction strategy changes should only be implemented after a series of cases have been analysed. This will avoid changes being made to the system based on idiosyncratic case features. However, to illustrate the changes that might be made, we outline some strategies that might at least be considered on the basis of this case analysis.
- 1.
Equipment malfunctions such as the bed in theatre should be fixed quickly. A formalised responsibility and communication
Discussion
The benefits of analysing either a single case or series of cases using a formal set of human factors methods are that it allows the analysis of adverse clinical events to follow a structured format underpinned by robust psychological constructs. Analysis using Reason’s model not only allows clinicians to identify active failures, but also the potentially more important latent failures which initiate the antecedent conditions which allow people to make mistakes. Analysis of this case has
Acknowledgements
Dr Sally Adams would like to thank Healthcare Risk Resources International for funding her position at the Clinical Risk Unit.The authors would also like to thank Ms Anne O’Connor for reviewing the clinical aspects of this case.
References (21)
- Andrews, L.B., Stocking, C., Krizek, T., Gottlieb, L., Krizek, C., Vargish, T., Siegler, M., 1997. An alternative...
- Bognor, M.S., 1994. Human Error in Medicine. Lawrence Erlbaum, Hillsdale,...
- Booth, R.T., Boyle, A.J., Glendon, A.I., Hale, A.R., Waring, A.E., 1989. CHASE II: The Complete Health and Safety...
- et al.
Incidence of adverse events and negligence in hospitalised patients: results of the harvard medical practice study I
New England Journal of Medicine
(1991) - Cook, R.I., Woods, D.D., 1994. Operating at the sharp end: the complexity of human error. In: Bognor, M.S. (Ed.), Human...
- et al.
An analysis of major errors and equipment failures in anaesthesia management considerations for prevention and detection
Anaesthesiology
(1984) - et al.
Accident analysis of large scale technological disasters: applied to anaesthetic complications
Canadian Journal of Anaesthesia
(1992) A plea for the uniform registration of operation results
British Medical Journal
(1908)- Hurst, N.W., Ratcliffe, K., 1994. Development and application of a structured audit technique for the assessment of...
Error in medicine
Journal of the American Medical Association
(1994)
Cited by (42)
Risk assessment analysis of the future technical unit dedicated to the evaluation and treatment of motor disabilities
2011, Annals of Physical and Rehabilitation MedicineCitation Excerpt :Usually, healthcare professionals conduct risk assessments once an event has already occurred. The approach is centered on the organization and not on the individual; the human error is considered to be a constant factor to be taken into account in the design of new organizations, based on the REASON model [4,7,10,16,19,21,22]. Now we see emerging the notion of risk assessment before the event occurs and several studies have been conducted on the relevance of combining these two approaches [1–3,8,11,14,17,20,23] or working on safety barriers [9,15].
Decoding the perioperative process breakdowns: A theoretical model and implications for system design
2010, International Journal of Medical InformaticsNew approaches to researching patient safety
2009, Social Science and MedicineA quantitative approach to clinical risk assessment: The CREA method
2006, Safety Science