Implementing a human factors approach to RCA2: Tools, processes and strategies.
Root Cause Analysis and Action (RCA2) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and development of systems‐level interventions. We recently integrated a complement of human factor...
| Publicado en: | Journal of Healthcare Risk Management Vol. 41; no. 1; pp. 31 - 47 |
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| Autores principales: | , , , |
| Formato: | CEU questionnaire/scale research tables/charts Journal Article |
| Publicado: |
Wiley-Blackwell
Jul2021
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=151470243&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 151470243 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 10744797 53UI jtl: Journal of Healthcare Risk Management issn: 10744797 maglogo: Y pubinfo: dt: Jul2021 vid: 41 iid: 1 pid: 480 pub: Wiley-Blackwell place: Malden, Massachusetts artinfo: ui: 151470243 147665723 151470243 151470243 10.1002/jhrm.21454 151470243 ppf: 31 ppct: 16 formats: tig: atl: Implementing a human factors approach to RCA2: Tools, processes and strategies. aug: au: Wiegmann, Douglas A. Wood, Laura J. Solomon, Demetrius B. Shappell, Scott A. affil: Department of Industrial and Systems Engineering, University of Wisconsin‐Madison, 1513 University Ave, Madison WI, 53706,, USA sug: subj: Root Cause Analysis Program Implementation Risk Management Methods Adverse Health Care Event Human Education, Continuing (Credit) Qualitative Studies Human Error Patient Safety Job Satisfaction Implementation Science Academic Medical Centers Leadership Workload Organizational Structure ab: Root Cause Analysis and Action (RCA2) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and development of systems‐level interventions. We recently integrated a complement of human factors tools into the RCA2 process to address this gap. These tools include the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a multiple‐criterion decision tool called FACES, for selecting effective HFIX solutions. We describe each of these tools and illustrate how they can be integrated into RCA2 to create a robust human factors RCA process called HFACS‐RCA2. We also present qualitative results from an 18‐month implementation study within a large academic health center. Results demonstrate how HFACS‐RCA2 can foster a more comprehensive, human factors analysis of serious patient harm events and the identification of broader system interventions. Following HFACS‐RCA2 implementation, RCA team members (risk managers and quality improvement advisors) also experienced greater satisfaction in their work, leadership gained more trust in RCA findings and recommendations, and the transparency of the RCA process increased. Effective strategies for overcoming implementation barriers, including changes in roles, responsibilities and workload will also be presented. pubtype: Academic Journal doctype: CEU questionnaire/scale research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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