247
Chapter 29
Using Human Factors
Engineering to Improve Root
Cause Analysis Efforts
Bridget O’Hare
Root Cause Analysis
A root cause analysis, or RCA, is an investigation of an accident or near-miss accident to learn
what factors contributed to the event. A typical root cause analysis in healthcare is a methodology
or process used to nd out what went wrong, and more importantly, what contributed or caused a
medical error or near miss that produced harm or could have caused harm to a patient. In addition
to the discovery of the root cause(s), a plan of action is developed to mitigate the risk of the event
happening again. A successful plan of action to prevent the reoccurrence of the medical error or
opportunity for error will include human factors engineering principles and practices.
e primary reason that an RCA is used in healthcare is to identify what caused or likely
caused a medical accident so that eorts can be made to prevent the medical accident or reduce the
risk of the event in the future. Healthcare providers are committed to helping patients and doctors
take an oath to “First do no harm.” Healing, not harming, the patient is a healthcare practitioner’s
primary passion. Practitioners expect perfection in patient care and their life is dedicated to help-
ing their patients to heal.
e vast majority of healthcare workers are conscientious and they carry the weight of errors
with them always. ose healthcare workers directly involved in a medical accident, or those at
the “sharp end of the knife” are often referred to as the second victim. e sta and employees
Contents
Root Cause Analysis .................................................................................................................247
Human Factors Enginering ..................................................................................................... 248
Endnotes ..................................................................................................................................250
248 ◾ Bridget O’Hare
involved in healthcare accidents are highly motivated and deeply moved to make changes to pre-
vent the same mishap from happening again. Part of a healthcare worker’s healing process, when
they have contributed to an error, is to be part of the process to change or prevent another medical
accident. ey are often powerful members of an RCA team when they are part of a nonpunitive
and transparent environment. An organization that focuses on learning from errors so that they
are not repeated is more likely to improve safety.
1
A second reason for conducting an RCA is to prevent an accident reoccurrence because such
errors are costly to an organization and ultimately to individual practitioners, increasing both dol-
lar and time costs for malpractice insurance, claims, and legal settlements. Intangible factors and
loss of market share are also a concern when harmed patients and their families share the personal
impact of medical errors with their families and friends.
A number of techniques and tools are often used in an RCA to determine what happened
or what went wrong, such as employee interviews, walkthroughs of the environment where the
event or near miss opportunity occurred, owcharting the process of what actually occurred,
owcharting the process of what normally happens, owcharting the process of what should
occur, compiling patient timelines, and reviews of the patient’s medical record documentation.
e information gained from the review provides information, which when compared to what
normally happens or should happen,
2
will often highlight what went wrong and what contrib-
uted to the error or near miss. It is benecial to include individuals in the investigation who were
not directly involved in the event, and also those who were present at the time of the event or
near miss. A robust investigation will include an experienced interviewer and someone with a
background in human factors engineering.
Human Factors Engineering
e incorporation of human factors engineering in a root cause analysis helps the team create
robust action plans. is is an essential ingredient to minimize and prevent errors from repeating.
e principles and practice of human factors engineering (HFE) focus on understanding human
limits, (e.g., cognitive, auditory, visual, etc.) in the design of systems, interactions, and processes.
By using these principles and incorporating them into action plans, HFE helps to design or rede-
sign better systems that make it possible and easier to do the right thing and impossible or dicult
to do the wrong thing.
Several examples of the successful implementation of human factors engineering have been
used in other high-risk, high-reliability environments for more than four decades. e aviation
industry, for example, has successfully reduced the opportunity for error or an airplane crash and
the National Transportation Safety Board (NTSB, 1990) estimates that a passenger boarding a
US carrier has over a 99.99 percent chance of surviving the ight. Healthcare has begun to imple-
ment actions aimed at preventing medical errors and injuries to patients using the power of human
factors engineering to create forcing functions and system engineering changes in the design of
equipment and work processes to prevent bad outcomes.
A research study was performed in healthcare to address two near misses and one sentinel
event that resulted from poor hando communication of critical cardiac alarm information. HFE
was used to improve the response time to (tend to) the patient and it improved the communication
and the timeliness of response to life critical telemetry alarms at a 1,061 bed tertiary care hospital
with 264 telemetry monitoring system channels.
3
In contrast, the research also pointed out that
standardization of the process and education eorts alone using a pager to communicate cardiac
Using Human Factors Engineering to Improve Root Cause Analysis Efforts ◾ 249
alarms did not show a change in pager response time. Standardization and education of the alarm
communication process using the one-way communication of an alpha-pager was compared with
a new bidirectional communication badge.
e use of a communication badge with bidirectional communication fostered a closed loop
of communication or hando of information from the centralized telemetry technician with the
nurse caring for the patient. ere were no sentinel events or known near misses following the
implementation of the communication badge compared with previous periods of similar duration
where two near misses and one sentinel event occurred.
e communication badge featured hands-free operation, voice activation, and an automated
escalation pathway to support human-to-human contact. e badge had a signicant impact on
alarm management for the nursing areas. “e direct communication functionality of the badge
signicantly shortened the time to rst contact, time to completion, and rate of closure of the
communication loop in both the pilot and study phases. Median time to rst contact with the
communication badge was 0.5 minutes, compared to 1.6 minutes with the pager communication
(p < 0.0003). Communication loop closure was achieved in 100% of clinical alarms using the
badge versus 19% with the pager (p < 0.0001).”
4
Previously, the alarms went into a queue of pages
awaiting response with a one-way communication device. e badge had the advantage of foster-
ing human voice-to-voice interaction and the power of intonation to communicate the criticality
of the cardiac alarm and these features were perceived to be factors in reducing the alarm response
time. e improvement in response time was used as a measure of the clinical information hand-
o. By supporting the timely closure of the alarm, the new process allowed both the telemetry
technicians and the nurses to focus on the priorities at hand rather than having incomplete alarm
notications waiting for a conrmation call. Use of the improved communication tools and pro-
cesses, thus getting to the patient faster, could positively inuence patient outcomes.
At a large multihospital system, human factors engineering principles were used in a “never
means never” initiative to prevent operations on the wrong surgical site, wrong patient, and the
prevention of unintended retained foreign objects.
5
One HFE component included adding a forc-
ing function, or a bright orange towel with the words “TIME OUT” inscribed for every surgical
procedure. Human memories are fallible and sometimes there are errors of omission when indi-
viduals believe that they have performed a task when, in fact, they have not. e towel was used
as a mental trigger to help them remember to perform the timeout. is is a critical safety check
or conrmation of the correct patient, the correct site, and the correct procedure. e towel was
incorporated into the sterile surgical packages so that it was present during presurgical prepara-
tion of supplies and equipment in the operating room. e towel was consistently placed over the
knife or instruments on the Mayo stand or over the surgical site. It would be dicult to ignore
the “TIME OUT” message because the act of moving the towel to perform the next step in the
surgical process, or incision, would require the surgeon to look at the towel to get to the scalpel or
surgical instrument.
Another example of HFE used in the never means never initiative was the order of the timeout,
which incorporated cognitive psychology and the known hierarchy that exists in the surgical envi-
ronment. From prior events and near misses, it was known that sta would not always question
the surgeon if the surgeon began the timeout and said, for example, “is is Jane Smith and we are
going to perform a left arthroscopic knee procedure.” Sta might assume the surgeon was in charge
and that they must know the procedure that they are performing or that they had intentionally
changed course if that is not what they believed to be true about the procedure. e remaining
members of the surgical team would nod in conrmation, but they did not always participate in
an active way, nor were they cognitively engaged in the timeout process. Because they were not
250 ◾ Bridget O’Hare
cognitively engaged or fully present, there was not a true double check of the correct patient, cor-
rect site, or correct procedure during the timeout process. By having the surgeon initiate, but not
call out the procedure details until after all other members of the surgical team conrmed their
scripted role, two things began to happen. First, the sta perceived that the surgeon supported
the timeout process by initiating it. And second, by considering the known hierarchy that often
exists in the perioperative environment and having the surgeon speak up last in the scripted roles,
intentional redundancy was facilitated rather than impeded. is technique to ensure full team
cognitive engagement should minimize the risk of an incorrect procedure or incorrect patient.
Another HFE practice helped to standardize counting practices and reduced the number of
unintended retained foreign objects. e hospital system standardized the method for counting
used sponges by implementing the consistent use of sponge counting bags (that hang from an IV
pole) and implementing a standardized, two-person counting process, recording the count infor-
mation on a preformatted white board to account for used surgical sponges and reconcile them
against the baseline count. Better human factors engineering controls existed as each used sponge
was placed in its own unique bag and the operating room team was able to see what had been
separated and counted. e new process aids human visual limitations by making it possible for
the entire perioperative team to clearly see the sponges against a darker background. e sponge-
counter bags were hung at the appropriate line of sight for the standing surgical team members.
Previous counting practices included placing previously counted, rolled sponges on the oor on
disposable towels. e counting practices varied and the accountability of used sponges was even
more dicult when shift changes occurred prior to the completion of a surgical case.
A root cause analysis is a tool that is used to determine what contributed or caused a near
miss or harm to a patient. e incorporation of HFE practices and principles in the RCA action
plans is a helpful mechanism to eliminate and minimize repeat events or near misses. Because it
specically takes human factors and fallibility into account, HFE has been shown to create bet-
ter controls and improved patient care practices, which further limit the risk of adverse patient
outcomes due to medical errors.
Endnotes
1.
M. D. Winokur and Kay Beauregard, R.N., “Patient Safety: Mindful, Meaningful, and Fullling,”
Frontiers of Health Services Management 22, no. 1 (2005): 17–28.
2. David Marx, “Just Culture,” Outcome Engenuity, 2011, http://www.outcome-eng.com/.
3.
Kimberly Bonzheim, Bridget O’Hare, et al., “Communication Strategies and Timeliness of Response to
Life Critical Telemetry Alarms,” Telemedicine and e-Health 17 (May 2011).
4.
Kimberly Bonzheim, Bridget O’Hare, et al., “Communication Strategies and Timeliness of Response to
Life Critical Telemetry Alarms,” Telemedicine and e-Health 17 (May 2011), 241.
5. Kathleen Harder, PhD, University of Minnesota, designed the safe surgery process together with the
author, et al, at Banner Health, Never Means Never Initiative, 2009–2012.
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