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

Abstract. The Human Factors Analysis and Classification System (HFACS) methodology was applied to accident reports from three African countries: Kenya, Nigeria, and South Africa. In all, 55 of 72 finalized reports for accidents occurring between 2000 and 2014 were analyzed. In most of the accidents, one or more human factors contributed to the accident. Skill-based errors (56.4%), the physical environment (36.4%), and violations (20%) were the most common causal factors in the accidents. Decision errors comprised 18.2%, while perceptual errors and crew resource management accounted for 10.9%. The results were consistent with previous industry observations: Over 70% of aviation accidents have human factor causes. Adverse weather was seen to be a common secondary casual factor. Changes in flight training and risk management methods may alleviate the high number of accidents in Africa.

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Human factors evaluation of automatic external defribillators in a hospital setting

PsycEXTRA Dataset ◽

10.1037/e577642012-038 ◽

2006 ◽

Author(s):

Munira Jessa ◽

Joseph Cafazzo ◽

Anjum Chagpar ◽

Richard Cooper ◽

Randy Wax ◽

...

Keyword(s):

Human Factors ◽

Hospital Setting

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Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review

BMJ Open ◽

10.1136/bmjopen-2020-047102 ◽

2021 ◽

Vol 11 (5) ◽

pp. e047102

Author(s):

Gemma Louch ◽

Abigail Albutt ◽

Joanna Harlow-Trigg ◽

Sally Moore ◽

Kate Smyth ◽

...

Keyword(s):

Learning Disabilities ◽

Patient Safety ◽

Adverse Events ◽

Grey Literature ◽

Good Practice ◽

Hospital Setting ◽

Eligibility Criteria ◽

Infant Outcomes ◽

Safety Outcomes

ObjectivesTo produce a narrative synthesis of published academic and grey literature focusing on patient safety outcomes for people with learning disabilities in an acute hospital setting.DesignScoping review with narrative synthesis.MethodsThe review followed the six stages of the Arksey and O’Malley framework. We searched four research databases from January 2000 to March 2021, in addition to handsearching and backwards searching using terms relating to our eligibility criteria—patient safety and adverse events, learning disability and hospital setting. Following stakeholder input, we searched grey literature databases and specific websites of known organisations until March 2020. Potentially relevant articles and grey literature materials were screened against the eligibility criteria. Findings were extracted and collated in data charting forms.Results45 academic articles and 33 grey literature materials were included, and we organised the findings around six concepts: (1) adverse events, patient safety and quality of care; (2) maternal and infant outcomes; (3) postoperative outcomes; (4) role of family and carers; (5) understanding needs in hospital and (6) supporting initiatives, recommendations and good practice examples. The findings suggest inequalities and inequities for a range of specific patient safety outcomes including adverse events, quality of care, maternal and infant outcomes and postoperative outcomes, in addition to potential protective factors, such as the roles of family and carers and the extent to which health professionals are able to understand the needs of people with learning disabilities.ConclusionPeople with learning disabilities appear to experience poorer patient safety outcomes in hospital. The involvement of family and carers, and understanding and effectively meeting the needs of people with learning disabilities may play a protective role. Promising interventions and examples of good practice exist, however many of these have not been implemented consistently and warrant further robust evaluation.

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On the Influence of Human Factors on Safety of Remotely-Controlled Merchant Vessels

Applied Sciences ◽

10.3390/app11031145 ◽

2021 ◽

Vol 11 (3) ◽

pp. 1145

Author(s):

Krzysztof Wróbel ◽

Mateusz Gil ◽

Chong-Ju Chae

Keyword(s):

Human Factors ◽

Human Factor ◽

Potential Influence ◽

General Belief ◽

Causal Factors ◽

Physiological Conditions ◽

Factors Analysis ◽

Important Barrier ◽

Human Operators ◽

Expert Study

With numerous efforts undertaken by both industry and academia to develop and implement autonomous merchant vessels, their safety remains an utmost priority. One of the modes of their operation which is expected to be used is a remote control. Therein, some, if not all, decisions will be made remotely by human operators and executed locally by a vessel control system. This arrangement incorporates a possibility of a human factor occurrence. To this end, a variety of factors are known in the literature along with a complex network of mutual relationships between them. In order to study their potential influence on the safety of remotely-controlled merchant vessels, an expert study has been conducted using the Human Factors Analysis and Classification System-Maritime Accidents (HFACS–MA) framework. The results indicate that the most relevant for the safety of this prospective system is to ensure that known problems are properly and timely rectified and that remote operators maintain their psycho- and physiological conditions. The experts elicited have also assigned higher significance to the causal factors of active failures than latent failures, thus indicating a general belief that operators’ actions represent the final and the most important barrier against accident occurrence.

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Scale of adverse events associated to nursing practices: a psychometric study in Portuguese hospital context

Revista Latino-Americana de Enfermagem ◽

10.1590/1518-8345.2595.3093 ◽

2018 ◽

Vol 26 ◽

Author(s):

Teresa Neves ◽

Vitor Rodrigues ◽

João Graveto ◽

Pedro Parreira

Keyword(s):

Adverse Events ◽

Public Hospital ◽

Hospital Setting ◽

Cross Sectional Study ◽

Cross Sectional ◽

Stable Factor ◽

Hospital Units ◽

Northern Regions ◽

Structural Invariance ◽

The Stability

Objective to contribute to the validation study of the Scale of Adverse Events associated with Nursing Practices in the hospital context. Method cross-sectional study, in public hospital units, in the central and northern regions of Portugal. The exploratory factor analysis of the Scale of Adverse Events associated to Nursing Practices was conducted with a sample of 165 nurses and the confirmatory factorial analysis was made with a sample of 685 nurses. Reliability, internal consistency and construct validity were estimated. The invariance of the model was evaluated in two subsamples to confirm the stability of the factorial solution. Results the global sample consisted of 850 nurses aged between 22 and 59, mostly licensed professionals. The model had a good overall fit in the subscales (Nursing Practices: χ2/df = 2.88, CFI = 0.90, GFI = 0.86, RMSEA = 0.05, MECVI = 3.30; Adverse Events: χ2/df = 4.62, CFI = 0.93, GFI = 0.95, RMSEA = 0.07, MECVI = 0.39). There was a stable factor structure, indicating strong invariance in the subscale Nursing Practices and structural invariance in the subscale Adverse Events. Conclusion the refined model of the Scale of Adverse Events associated with Nursing Practices revealed good fit and stability of the factorial solution. The instrument was adjusted to evaluate the perception of nurses about adverse events associated with health care, precisely nursing care, in the hospital setting.

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Effects of Maintenance Human Factors in Maintenance-Related Aircraft Accidents

Transportation Research Record Journal of the Transportation Research Board ◽

10.1177/0361198196151700103 ◽

1996 ◽

Vol 1517 (1) ◽

pp. 17-28

Author(s):

Matthew D. Dorn

Keyword(s):

Human Factors ◽

Process Analysis ◽

Frequency Of Occurrence ◽

Aircraft Accidents ◽

Causal Factors ◽

Process Level

To help prevent maintenance-related aircraft accidents the complex factors behind previous accidents must be understood. Maintenance-related aircraft accidents were studied to determine the effects of maintenance human factors. A taxonomy of causal factors was developed and used to classify the causes of 101 military and civilian accidents and to determine the frequency of occurrence for each factor. The taxonomy identifies elements, such as people and hardware, interfaces between elements (i.e., human factors), and maintenance processes comprised of elements and interfaces. Human factors were found to have a significant effect in the 86 military and 15 civilian maintenance-related accidents studied. Whereas investigation boards were found to focus most heavily on element failures, a majority of the failures were found to occur at the process level. Maintenance instructions and their interfaces with the maintainers and inspectors who use them were the most frequently failed elements and interfaces, respectively. Recommendations are made to guide further research, and ideas are provided for improving process analysis by maintenance units and investigation boards.

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Safety and Outcomes of Linezolid Use for Nocardiosis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa090 ◽

2020 ◽

Vol 7 (4) ◽

Cited By ~ 2

Author(s):

Natalie Davidson ◽

Matthew J Grigg ◽

Sarah L Mcguinness ◽

Robert J Baird ◽

Nicholas M Anstey

Keyword(s):

Adverse Events ◽

Hospital Setting ◽

Drug Susceptibility ◽

Therapeutic Drug ◽

Primary Analysis ◽

Safety And Efficacy ◽

Treatment Regimens ◽

Linezolid Therapy ◽

Tropical Australia ◽

Clinically Significant

Abstract Background Tropical Australia has a high incidence of nocardiosis, with high rates of intrinsic antimicrobial resistance. Linezolid, the only antimicrobial to which all local Nocardia species are susceptible, has been recommended in empirical combination treatment regimens for moderate–severe Nocardia infections at Royal Darwin Hospital (RDH) since 2014. We report the safety and efficacy of linezolid use for nocardiosis in this setting. Methods We identified cases through a retrospective review of all RDH Nocardia isolates from December 2014 to August 2018 and included 5 linezolid-treated cases from a previous cohort. Laboratory, demographic, and clinical data were included in the primary analysis of safety and treatment outcomes. Results Between 2014 and 2018, Nocardia was isolated from 35 individuals; 28 (80%) had clinically significant infection and 23 (82%) received treatment. All isolates were linezolid-susceptible. Safety and efficacy were assessed for 20 patients receiving linezolid-containing regimens and 8 receiving nonlinezolid regimens. Median linezolid induction therapy duration was 28 days. Common adverse effects in those receiving linezolid were thrombocytopenia (45%) and anemia (40%). Adverse events prompted discontinuation of trimethoprim-sulfamethoxazole more often than linezolid (40% vs 20%). Linezolid therapeutic drug monitoring was used in 1 patient, with successful dose reduction and outcome. There was no difference in 30-day survival between those treated with linezolid (90%) vs no linezolid (87%). One Nocardia-attributed death occurred during linezolid therapy. Conclusions Linezolid is safe and efficacious in empirical treatment for moderate to severe nocardiosis in a monitored hospital setting, with 100% drug susceptibility and no difference in adverse events or outcomes compared with nonlinezolid regimens.

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Forensic Human Factors: People, Places, Products

Reviews of Human Factors and Ergonomics ◽

10.1518/155723408x342862 ◽

2008 ◽

Vol 4 (1) ◽

pp. 75-104

Author(s):

Ilene Zackowitz ◽

Alison Vredenburgh

Keyword(s):

Human Factors ◽

Content Areas ◽

Causal Factors

Forensic human factors (HF) consultants apply the science of human factors to litigation. After someone has been injured and a lawsuit has been filed, attorneys will often seek the expertise of forensic HF consultants to analyze the incident and determine if features of the person, place, or product involved were causal factors in the incident. In this chapter we describe the conventions, guidelines, and procedures involved in a typical forensic HF case. In addition, we describe the human factors content areas that are most frequently addressed over the course of an HF evaluation.

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