Utilizing Human Factors to Improve Perioperative Adverse Event Investigations: An Integrated Approach

Abstract

ObjectiveApply Human Factors (HF), systems engineering, and high reliability organizational principles to improve adverse event investigations in a regional hospital system. BackgroundGiven the complexity of medicine and healthcare systems, innovative thinking is required to ensure these systems are resilient to error. Understanding the work system and its constituent parts is fundamental to understanding how errors begin and propagate. MethodThis paper provides a discussion on employing a systems-based approach to improve perioperative adverse event investigations within a hospital system. ResultsData was collected across 13 investigations. The findings are summarized into 16 contributing factors, with 10 specific examples of critical/serious risks that were addressed by the hospital system. ConclusionModern medicine needs to look to HF to improve safety and reduce errors. This manuscript provides a systems-based approach grounded in HF and organizational theories to improve how investigations are conducted and the approach to human error within a large hospital system. ApplicationThis work provides practical guidance for those who want to improve postoperative investigations within their own units or hospitals. PrecisThis article describes research that evolves the approach to accident investigation to improve perioperative adverse event investigations in hospital settings.