Human Factors Matrix
The Institute for Healthcare Improvement defines human factors as “the study of all factors that make it easier to do work in the right way.” When human factors principles are applied during a root cause analysis, they can help your team identify strong strategies to improve patient safety. Please see the factors in the table below, or download a PDF.
Skill-Based Human Factor:
Performance of familiar acts in routine environments
| Type | Prevention Strategy | Process Improvement Considerations | Strategies |
|---|---|---|---|
| Slip | Stop and think before acting | Automation interruption reduction • Self-checks • Second-person checks | Eliminate or reduce distractions ● Redundancy • Double checks |
| Lapse | Check and review | Visual cues and reminders ● Checklists ● Self-checks ● Second-person checks ● Verification points | Eliminate look-alikes and sound-alikes ● Checklist or cognitive aid ● Software enhancements or modifications |
| Fumble | Improve component design | ● Component design | Architectural or physical plant changes ● Forcing functions (engineering controls) ● Standardizing equipment or processes |
Rule-Based Human Factor:
Performance of acts or tasks that require application of rules accumulated through experience and training
| Type | Prevention Strategy | Process Improvement Considerations | Strategies |
|---|---|---|---|
| Incorrect rule | Educate | Procedure correction ● Procedure standardization ● Procedure detail and clarity | Forcing functions (engineering controls) ● Standardizing equipment or processes |
| Mis-application of a rule | Critical thinking | Procedure detail and clarity ● Educate or train on rule application | Checklist or cognitive aid ● Software enhancements or modifications ● Simulation |
| Non-compliance with a rule | Reduce burden | Task simplification ● Intuitive work environment ● Component design ● Task location ● Distinguish changes or differences ● Job aids at the work site | Simplify processes and remove unnecessary steps ● Architectural or physical plant changes ● Increase staffing or decrease workload |
Knowledge-Based Human Factor:
Performance of acts related to new or unfamiliar situations that require problem solving or when a rule does not exist or is unknown to the performer
| Type | Prevention Strategy | Process Improvement Considerations | Strategies |
|---|---|---|---|
| Operating outside of expertise | Stop and find an expert | Educate or train on rules and rule application ● Improve teamwork and communication ● Progressive discipline if appropriate (Just Culture Algorithm) | Enhanced documentation and communication ● Give or request a read back ● Independent verification ● Usability testing for new devices |
| No rule | Establish rule | ● Evidence-based best practice | Eliminate look-alikes and sound-alikes ● Checklist or cognitive aid ● Software enhancements or modifications |
Document adapted from the skills, rules, and knowledge classification scheme, developed by Jens Rasmussen and the Generic Error Modelling System, developed by James Reason.
