Citation

Canham A, Thomas Jun G, Waterson P, Khalid S. Appl. Ergon. 2018; 72: 1-9.

Affiliation

University Hospitals of Leicester NHS Trust, Leicester, UK.

Copyright

(Copyright © 2018, Elsevier Publishing)

DOI

10.1016/j.apergo.2018.04.012

PMID

29885719

Abstract

There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual-based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.

Copyright © 2018 Elsevier Ltd. All rights reserved.

Language: en

Keywords

Incident analysis; Patient safety; Systemic accident analysis