Human factors and healthcare-related deaths: review of coronial findings using a human factors classification framework

Background: All deaths that occur following healthcare-related procedures in Australia are required to be investigated by a coroner to assist in identifying any factors that may have contributed to the death. Human factors classification tools can assist in the identification of causal factors for these types of adverse events. Aim: To assess the ability of a human factors classification tool to identify the causal and contributing factors of unexpected healthcare-related deaths. Method: A convenience sample of 48 coronial findings that involved unexpected deaths in healthcare in Australia were obtained. The human factors classification framework (HFCF) for patient safety was used to identify key precursor events, contributing factors and the prime causes of healthcare-related deaths. Correspondence analysis was used to examine the relationships between incident prime causes and characteristics of the event. Results: Staff action/ communication was the most common type of precursor event identified in all four precursor events. There were 112 contributing factors identified for the 48 incidents. Factors relating to the patient (38.4%), organisation (26.8%) or individual staff member (17.0%) were the most commonly identified contributing factors. Correspondence analysis for prime causes showed that skill-based errors were strongly related to performing medical tasks, rule-based errors were strongly related to both monitoring tasks and delays, and knowledge-based errors were strongly related to misdiagnoses. Conclusions: The HFCF for patient safety was able to be used to extract supplementary information regarding healthcare-related deaths from coronial findings to assist in examining the complex nature of these adverse events.