Human Factors Informs Development of Root-Cause Analysis Toolkit

“A simple way to think about human factors is designing for human use,” said A. Zach Hettinger, M.D., M.S., director of informatics research, National Center for Human Factors Engineering in Healthcare, and one of the researchers who developed a toolkit for root-cause analysis covered in a recent issue of the Journal of Healthcare Risk Management. Presenting October 28, 2013, at the American Society for Healthcare Risk Management annual conference in Austin, Texas, Hettinger described how his organization and other human factors and systems engineers developed the toolkit (a draft version is available online). They evaluated 334 root-cause analyses and 782 solutions implemented as a result of those analyses. For the 32 most recent cases, they also interviewed providers after solutions were implemented, beginning with open-ended questions. Solutions were placed into four categories based on their effectiveness and sustainability. Highly effective solutions included institutional changes (large, facility-wide investments) and changes to the information technology structure.