OPSC Patient Safety Minute | Tools for Oregon Facilities: A Human Factors Matrix & Podcast

When reviewing reports that Oregon facilities submit through the Patient Safety Reporting Program (PSRP), we often see human factors as a common theme. When human factors principles are applied during a root cause analysis, they can help your team identify strong strategies to improve patient safety.

How Human Factors Can Help

Combining Human Factors Engineering with an adverse event investigation helps identify system‑level causes rather than placing blame on individuals (which can be detrimental to learning and improvement!). This approach supports the development of new strategies and prevention methods that help providers and staff perform standard procedures safely and follow established policies. 

For example, in one report submitted to PSRP, a patient experienced a transfusion reaction after receiving blood in the emergency department. The event analysis identified several system-level factors (including a skill-based human factor) that played a role in the event. Their analysis looked at the equipment, policies, and procedures in the blood bank, as well as the design of the physical space. They were able to standardize equipment and simplify overly complicated procedures. But perhaps most significantly, they were able to modify the physical space to reduce interruptions and distractions.

Tools to Get You Started: A Human Factors Matrix & Podcast

Attention all hospitals! The Centers for Medicare and Medicaid Services (CMS) Patient Safety Structural Measure identifies human factors engineering principles as one of the high reliability practices that support a culture of safety in a learning health system.

Facilities can use the Human Factors Matrix to identify human factors that were involved in a patient harm event. This tool can also be used to review the associated process improvement considerations and strategies facilities can include in their action plans.

In addition, facilities can listen to a recent podcast from the Institute for Healthcare Improvement (IHI), The Real Reason Training Alone Cannot Fix Patient Safety with Professor Charles Vincent.

What More You Can Do

• Consider deepening your staff skillsets with the human factors certification program from IHI, Certified Professional in Human Factors in Health Care.

• Integrate a human factors approach during your root cause analysis, and then tell us what you learned using our new and improved adverse event reporting form! (‍We’ve made changes to PSRP to make it easier for you to report! ‍Over the last few months, we’ve been working on improving and modernizing Adverse Event Reporting through the Patient Safety Reporting Program, making it easier to gathering the information we need from your shared learning.)

Additional Resources

• Article from the Joint Commission: What Saves a Patient? A Human Factors Approach to Understanding Near Misses in the ICU

• Blog posts from the Institute for Healthcare Improvement (IHI):

  • To Err Is Human – To Design for Safety Is Essential: Why Human Factors Matters in Health Care

  • Why Every Health Care Organization Needs Human Factors Expertise, and How to Get There

• Article from ECRI: The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior Are Key to a Just Culture

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