A Human Factors Approach to Root Cause Analysis:

A Human Factors Approach to Root Cause Analysis: The Human Factors Analysis and Classification System (HFACS) Douglas A. Wiegmann, PhD University of Wisconsin-Madison

Human Error and Adverse Events Medical error is the 3 rd leading cause of death in the U.S. When such errors and events happen, a Root Causes Analysis (RCA) is conducted to determine why it happened and how it can be prevented from happening again. However, the causes of errors are manifold and often include complex human factors issues rather than individual incompetence. Therefore, any RCA of a patient harm event cannot be considered thorough and credible unless it effectively examines the human factors that underlie errors.

What is Root Cause Analysis (RCA)? RCA is a commonly used process and set of tools for discovering the underlying factors that contribute to accidents or injuries. Goal is to figure out what happened, why did it happen, and how can it be prevented from happening again? Process involves several major steps: Gathering information Analyzing information Drawing Conclusions Making Recommendations Implementing Changes Evaluating Outcomes

General RCA Process Event, hazard, system vulnerability Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event RCA Tools HFACS Lite What happened? Fact finding and flow diagramming What happened? Development of causal statements Why did it happen? Identification of solutions and corrective actions Implementation How can it be prevented from happening again? Measurement Feedback Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm

What is RCA? Traditional RCA was developed as an engineering method for discovering the causes underlying equipment and material failures. Engineers in the aerospace industries, such as NASA developed RCA tools for gathering information to understand why a piece of technology (like a rocket engine) may have failed and caused a spaceship to crash. They developed these tools based on their knowledge of the basic physical sciences, such as physics and chemistry, as well as mathematics. These tools help investigators frame their thinking about causality, ask the right questions about why things failed, gather important engineering data relevant to answering these questions, and analyzing findings in a systematic and reliable fashion based on science. This is where many of our RCA tools today come from, such as fault trees, as well as our assumptions about root causes and the 5 Whys heuristic.

Does RCA Work? RCA is an effective engineering method for discovering the causes underlying equipment and material failures. However, current RCA methods and tools were NOT designed to identify human factors causes of errors. (They are based on the physical sciences not the human sciences. ) Hence, they do NOT help investigators to frame their thinking about causality, ask the right questions about why errors occurred, gather important human factors data relevant to answering these questions, and analyzing findings in a systematic and reliable fashion based on science. Thus, when RCA methods are used to investigate medical error-related events, they typically produce superficial results, often focusing on who did what. Any attribution of cause is often only speculative or subtly veiled blame. The results from such reports identify few opportunities for implementing substantive change. Consequently, RCA has NOT been an effective method for analyzing and correcting human factors issues that produce errors and lead to patient harm.

What do we do now? 1. Discard RCA altogether and try something else. 2. Continue using traditional RCA tools even though they don t work well. 3. We can try to come up with our own tools based on personal preferences or opinions. 4. We can adopt RCA Tools that are based on human factors science.

Redesigning RCA The Human Factors Analysis and Classification System (HFACS) and the Human Factors Intervention Matrix (HFIX) were designed to transform RCA into an effective error analysis and prevention technique. Organizational Influences Organizational Culture Operational Process Resource Managemen t Supervisory Factors Inadequate Supervision Planned Inappropriate Failure To Correct Operations Known Problem Supervisory Violation Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Techn ology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Unsafe Acts Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Violations Exceptional Violations

HFACS-RCA Process Event, hazard, system vulnerability Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements Identification of solutions and corrective actions HFIX Implementation Measurement Feedback (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)

HFACS HFACS was originally designed to facilitate the investigation of human errors in aviation. HFACS has now been applied in variety of industries including mining, construction, petrochemical, and healthcare. Numerous studies have demonstrated its usability, comprehensiveness, and reliability.

Swiss Cheese Model ORGANIZATIONAL INFLUENCES SUPERVISORY FACTORS PRECONDITIONS FOR UNSAFE ACTS UNSAFE ACTS

Swiss Cheese Model Key Points: 1. Holes represent a failure or absence of safety barriers. 2. Not every failure will lead to an accident (holes may be inconsequential or plug themselves). 3. Multiple failures (holes) can occur at each level, not just a single hole. 4. Not every accident will have organizational roots (but you must look for them). 5. Failures across levels interact and follow a logical sequence (no tier jumping). 6. The farther down the system a hole is plugged, the more localized the fix will be. 7. The farther up the system a hole can be plugged, the broader impact it will have a safety. But what are the holes in the cheese?

Unsafe Acts Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Violations Exceptional Violations

Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Decision Errors These thinking errors represent conscious, goal-intended behavior that proceeds as intended, yet the plan proves inadequate or inappropriate for the situation. These errors typically result from a lack of information, knowledge or experience.

Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Skill-based Errors Highly practiced behavior that occurs with little or no conscious thought. These doing errors frequently appear as attention failures, memory failures, or errors associated with the technique with which one performs a task.

Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Perceptual Errors These errors involve the five senses: seeing, hearing, touching, tasting, and smelling. It is not unusual for these senses to become inaccurate or confused in sensory impoverished environments or degraded simply due to normal aging.

Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations

Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Routine Violations Often referred to as bending the rules, this type of violation tends to be habitual by nature, engaged in by others, and is often enabled by a system of supervision and management that tolerates such departures from the rules.

Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Exceptional Violations Isolated departures from the rules, neither typical of the individual nor condoned by management.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Mental State Psychological/mental conditions that negatively affect performance such as mental fatigue, pernicious attitudes, misplaced motivation, and cognitive states such as distraction, mental workload, and confusion.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Physiological State Medical/physiological conditions that preclude safe operations such as illness, intoxication, and the myriad of pharmacological and medical abnormalities known to affect performance.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Fitness for Duty Off-duty activities that negatively impact performance on the job such the failure to adhere to sleep/rest requirements, alcohol restrictions, and other off-duty mandates.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Tools/Technology This category encompasses a variety of issues including the design of equipment and controls, displays/interface characteristics, checklist layout, and automation.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Task Refers to the nature of the activities performed by individuals and teams including such things as the complexity, criticality, and consistency of assigned work.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Physical Environment This category includes the setting in which the individual performs their work and consists of such things as lighting, layout, noise, clutter, and workplace design.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Leadership The team leader s performance of his/her responsibilities such as the failure to adopt a leadership role or model/reinforce principles of teamwork.

Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Communication The sharing of information among team members including providing/requesting information and the failure to provide two-way (positive confirmation) communication.

Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation

Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Inadequate Supervision Oversight and management of personnel and resources, including training, professional guidance, and operational leadership.

Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Planned Inappropriate Operations Management and assignment of work including aspects of risk management, staff assignment, work tempo, scheduling, etc.

Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Failure to Correct Known Problems Those instances when deficiencies among individuals or teams, problems with equipment, or hazards are known to the supervisor but are allowed to continue unabated.

Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Supervisory Violation The willful disregard for existing rules, regulations, instructions, or standard operating procedures by management during the course of their duties.

Organizational Culture Organizational Influences Operational Process Resource Management

Organizational Culture Organizational Influences Operational Process Resource Management Organizational Culture The shared values, beliefs, and priorities regarding safety that govern organizational decision making, as well as the willingness of an organization to openly communicate and learn from adverse events.

Organizational Culture Organizational Influences Operational Process Resource Management Operational Process Refers to how an organization plans to accomplish its mission, as reflected by its strategic planning, policies/procedures and corporate oversight.

Organizational Culture Organizational Influences Operational Process Resource Management Resource Management Refers to the support provided by senior leadership to accomplish the objectives of the organization including the allocation of human, equipment/facility and monetary resources.

Organizational Culture Organizational Influences Operational Process Resource Management Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Correct Known Problem Supervisory Violation Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations

HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements HFACS Analysis Tools Identification of solutions and corrective actions HFIX-RCA Implementation HFACS Data Analytics Measurement Feedback HFIX Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)

HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements HFACS Analysis Tools Identification of solutions and corrective actions HFIX-RCA Implementation HFACS Data Analytics Measurement Local Feedback HFIX Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)

HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization HFIX-Global Major Event HFACS HFACS Lite Lite What happened? Fact finding and flow diagramming HFACS Trends Development of causal statements HFACS-RCA HFACS Analysis Tools Identification of solutions and corrective actions HFIX-RCA System Feedback HFACS Data Analytics Implementation Measurement HFACS-FMEA HFACS Observations HFACS Latent Factors Survey Closed-claim Cases/Prior RCAs Other sources Local Feedback HFIX-RCA Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)

HFACS-RCA Process Event, hazard, system vulnerability Near-Miss Investigation Process Minor Event Risk-based prioritization HFIX-Global Major Event HFACS HFACS Lite Lite Never Happens HFACS Trends System Feedback HFACS Data Analytics HFACS-FMEA HFACS Observations HFACS Latent Factors Survey Closed-claim Cases/Prior RCAs Other sources (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)

HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements HFACS Analysis Tools Identification of solutions and corrective actions HFIX Implementation HFACS Data and Analytics Measurement Local Feedback HFIX Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)

What can happen RCA Teams Acquire the ability to perform a more in-depth analysis of actual systemic or root causes of events Experience a greater feeling of ownership and commitment to the RCA process Greater conviction and satisfaction with their findings and recommendations Those involved in event: Heightened sense that their voices have been heard Improved attitude about the RCA Process Leadership Less scrutiny of analysis and findings and greater focus on solutions Increased buy-in of operational owners of the required changes Organization Transformation of culture from one of blame to one of a learning and just culture. Improved patient care and satisfaction Increased provider moral and professional pride in your healthcare system.

What can happen When we showed the Joint Commission our HFACS-RCA report, they said that it was the most thorough and credible RCA they had ever seen! J. Hood (ASHRM 2017 Annual Meeting)

Thank you! Douglas A. Wiegmann, Ph.D. (608)609-1100 dawiegmann@wisc.edu scott.shappell@erau.edu