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

Rebecca J. Mitchell*, Ann Williamson, Brett Molesworth

*Corresponding author for this work

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.

Original languageEnglish
Pages (from-to)185-195
Number of pages11
JournalApplied Ergonomics
Volume52
DOIs
Publication statusPublished - 1 Jan 2016

Keywords

  • Patient safety
  • Clinical incident
  • Classification framework
  • Error

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