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The development of a human factors classification framework for patient safety
  1. R Mitchell*,
  2. A Williamson,
  3. B Molesworth
  1. Correspondence Department of Aviation, University of New South Wales, Level 2, Old Main Building, Sydney, 2052, Australia

Abstract

Introduction Numerous taxonomies have been developed to attempt to identify the human factors contribution to adverse events in complex industries. In healthcare these taxonomies have often focused on outcomes, do not consider the temporal sequence of causal factors or assess framework reliability. The aims of this research are to develop a framework for human factors analysis of adverse medical events and to assess framework reliability in identifying the contribution of human factors and error to these events.

Method A multi-stage process was used to develop the framework. A systematic review of the literature identified existing human factors tools used in healthcare and other complex industries. A draft framework is in the process of review and refinement following classifications of adverse medical events in Australia to assess inter-rater reliability.

Results The framework allows for the classification of precursor events, that is, the causal chain which led directly to the event occurring, and contributing factors, that is, pre-existing conditions that led to the event occurring. The prime considerations in developing the tool have been good validity, a theoretical basis, comprehensive coverage of error types to allow understanding of cognitive failures, as well as evidence that the classification tool could be used reliably.

Conclusion The framework will provide opportunities to improve our understanding of adverse medical events by identifying the prime causal chain for these events, along with other contributing factors. The development of a reliable human factors classifi cation framework provides better direction for preventive efforts to reduce adverse medical events.

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