Application of human factors analysis and classification system model to event analysis in radiation oncology

Applying the human factors analysis and classification system to critical incident reports in anaesthesiology

“…This finding is supported by the problems encountered in applying those nanocodes that showed a comparatively low ratability score. This is partly due to the HFACS model per se, which includes an algorithm that focuses on the individual act and only thereafter moves upstream in the causal chain . It also has to be considered a systems property for anonymous reporting systems that provide a finite data set: Investigators have no means of clarifying ambiguous statements or gaining supplemental data from personal interviews with those involved.…”

“…To expand on this model with increased granularity, and provide a practical taxonomy at the same time, the Human Factors Analysis and Classification System (HFACS) was subsequently developed . Although initially applied to aviation, HFACS has successfully been modified and implemented in a variety of other high‐risk domains including mining, maritime and railway transport, construction and health care …”

Clinical practice workflow in Radiation Oncology should be highly standardized

“…These factors can be broadly categorized into buckets such as variations of clinical circumstances from patient to patient, the decisions of how to separate out different complexities of processes and steps (e.g., 2D, 3D Conformal, IMRT, SBRT, etc. for treatment planning processes), and last but by no means least, human factors of team members within each department . To use data that have very high standard deviations to set process step times and highly standardize an operation is unfortunately not realistic and leads to innumerable operational challenges and are not easily surmountable.…”

The association between event learning and continuous quality improvement programs and culture of patient safety

“…Furthermore, root causes (or key contributing factors) are identified and categorized using a high-level taxonomy (eg, "performance" issues [not following or understanding policies and procedures, sending suboptimal communications], lack of process standardization, technological/ environmental factors [difficulties with information technology, suboptimal workload, etc.]). 18 The number of events generated at each step and propagated from the prior steps and events caught and corrected at various steps in our workflows was used to estimate the utility of safety barriers at each process step, using the number of events caught by the safety barriers divided by the number of events that were presented to the safety barriers at the respective process step.…”