Elsevier

Safety Science

Volume 31, Issue 2, March 1999, Pages 143-159
Safety Science

Article
Applying human factors methods to the investigation and analysis of clinical adverse events

https://doi.org/10.1016/S0925-7535(98)00062-9Get rights and content

Abstract

Safety in medicine is a rapidly developing field. However, until recently it had been unclear how the skills and tools developed by human factors practitioners in other industries could be applied to medicine. This paper initially outlines the quality and safety programmes healthcare systems have traditionally used to improve quality of care, before turning our attention to the epidemiology of medical adverse events. The development of clinical risk management is explained, with a focus on how human factors methods could be used to assist safety management in healthcare. A formal and systematic method to investigate and analyse clinical adverse events and near misses is described, which is based on traditional human factors methodologies. The investigation of clinical adverse events utilises a semi-structured interview and performance influencing factor questionnaire, whilst Reason’s organisational accident causation model is used to analyse adverse events (Reason, J.T., 1993. The human factor in medical accidents. In: Vincent, C. (Ed.), Medical Accidents. Oxford Medical Publications, Oxford). An obstetrics case, concerning a post-partum haemorrhage is used to show how the investigative methods can be used by a clinical risk manager to build up an accurate and detailed description of what happened and the organisational accident causation model can be used to systematically identify why errors occurred. Finally, the applicability and necessary modifications of human factors methods for use in medicine are discussed.

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.

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