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

Abstract

Various human factors classification frameworks have been used to identified causal factors for clinical adverse events. A systematic review was conducted to identify human factors classification frameworks that identified the causal factors (including human error) of adverse events in a hospital setting. Six electronic databases were searched, identifying 1997 articles and 38 of these met inclusion criteria. Most studies included causal contributing factors as well as error and error type, but the nature of coding varied considerably between studies. The ability of human factors classification frameworks to provide information on specific causal factors for an adverse event enables the focus of preventive attention on areas where improvements are most needed. This review highlighted some areas needing considerable improvement in order to meet this need, including better definition of terms, more emphasis on assessing reliability of coding and greater sophistication in analysis of results of the classification.

Practitioner Summary: Human factors classification frameworks can be used to identify causal factors of clinical adverse events. However, this review suggests that existing frameworks are diverse, limited in their identification of the context of human error and have poor reliability when used by different individuals.

Keywords::

• patient safety
• hospital
• medical errors
• causal factors
• reliability

Acknowledgements

R. Mitchell was supported by an ARC-linkage post-doctoral fellowship (LP0990057). A. Williamson is supported by an NHMRC Senior Research Fellowship. The views expressed in this paper are the views of the authors that do not necessarily reflect the views or policies of the funding agencies.

Additional information

Funding

This research was funded by an Australian Research Council linkage grant (LP0990057) and the NSW Clinical Excellence Commission and the NSW Ministry of Health.