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Safety. Science. Solutions.

Event Reviews

Whether it is near-miss events that continue to occur, an adverse event that was too close for comfort, or a serious safety event that must never happen again, human factors engineering offers a unique systems perspective to a traditional root cause analysis.

Healthcare systems are complex, consisting of policies, medical devices, information systems, processes, and physical environments. At the center of this system are people: physicians, nurses, technicians, transporters, and a host of other specializations that provide the resilience of the healthcare system. When an unwanted event occurs, two actions are imperative: 1) understand why the event occurred, because if it made sense to one person to perform a particular action in one case, it will make sense to someone else to perform that action at a later time, and 2) develop a strategy to address the true root causes of an event. Too often, the resulting action after a root cause analysis is to implement a new policy or provide additional training. Unfortunately, research has demonstrated repeatedly that these are the least effective and least sustainable solutions to adverse events.

To understand why an event occurred, we need to examine the difference between “Work as Imagined” vs. “Work as Performed.” When people are doing things ‘wrong’, why is that the case? If policies are not being followed, we need to examine why. What are the work-arounds or shortcuts? We need to examine and address difficulty, complexity, variety, ambiguity, and sequence. Working through a systems analysis of the events will identify a healthcare system’s strengths and inform opportunities for improvement.

Healthcare Safety Strategies can send a review team to your facility to perform an independent review or you may choose to have a seasoned human factors engineer join your team during the review process. Contact us for more information.