Applying the Human Factors Analysis and Classification System within root cause analysis to prevent medical errors and enhancing patient safety culture: insights from a medical center

Jiun-Yih Lee; Chien-Hsien Huang; Yi-An Sie; Pei-Ching Yang; Chun-Cheng Su; Jui-Ting Chang

doi:10.1093/intqhc/mzaf009

Applying the Human Factors Analysis and Classification System within root cause analysis to prevent medical errors and enhancing patient safety culture: insights from a medical center

Int J Qual Health Care. 2025 Feb 27;37(1):mzaf009. doi: 10.1093/intqhc/mzaf009.

Authors

Jiun-Yih Lee¹, Chien-Hsien Huang^{2

3}, Yi-An Sie⁴, Pei-Ching Yang⁵, Chun-Cheng Su⁶, Jui-Ting Chang^{1

3

6}

Affiliations

¹ Center for Quality Management, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd., Shilin Dist., Taipei City, Taiwan (R.O.C.), Taipei 111, Taiwan.
² Division of Infectious Disease, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd., Shilin Dist., Taipei City, Taiwan (R.O.C.), Taipei 111, Taiwan.
³ College of Medicine, Fu-Jen Catholic University, No. 510, Zhongzheng Rd., Xinzhuang Dist., New Taipei City, Taiwan (R.O.C.), Taipei 242, Taiwan.
⁴ Central Sterile Supply Room, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd., Shilin Dist., Taipei City, Taiwan (R.O.C.), Taipei 111, Taiwan.
⁵ Department of Nursing, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd., Shilin Dist., Taipei City, Taiwan (R.O.C.), Taipei 111, Taiwan.
⁶ Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd., Shilin Dist., Taipei City, Taiwan (R.O.C.), Taipei 111, Taiwan.

PMID: 39936321
DOI: 10.1093/intqhc/mzaf009

Abstract

Introduction: Enhancing patient safety and minimizing medical errors are crucial in healthcare. While root cause analysis (RCA) is commonly used to investigate adverse events, its lack of human factor integration limits its effectiveness. The Human Factors Analysis and Classification System (HFACS), adapted from aviation to healthcare, systematically identifies human and organizational factors. However, the integration of HFACS into RCA and the impact of HFACS-RCA implementation remain underexplored. Therefore, this study aims to provide a practical case of HFACS integration into RCA and explore the effects of HFACS-RCA implementation.

Methods: This study integrates HFACS into the RCA process at a medical center in Taiwan, examining an incident involving unsterilized instruments distributed from the Central Sterile Supply Room (CSR) to the Intensive Care Unit (ICU). This study employed a before-and-after study design to examine the impact of the HFACS-RCA intervention. The primary outcome measures were the changes in scores across the eight dimensions of the Taiwan Patient Safety Culture Survey (TPSC) before and after the intervention.

Results: A 1-year follow-up of the CSR case showed no similar incidents. HFACS-RCA significantly improved TPSC scores in unit safety climate (P = .05), feelings toward management (P = .05), and job satisfaction (P = 0.05), while the other dimensions showed no significant changes.

Conclusion: HFACS-RCA application offers a comprehensive framework for identifying and mitigating factors contributing to medical errors, improving patient safety, and setting a precedent for future healthcare safety management research and practice.

Keywords: HFACS; RCA; patient safety; safety culture; sterilization process.

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MeSH terms

Ergonomics*
Humans
Intensive Care Units / organization & administration
Medical Errors* / prevention & control
Organizational Culture
Patient Safety* / standards
Root Cause Analysis* / methods
Safety Management* / methods
Taiwan