Implementing Root Cause Analysis and Action: Integrating Human Factors to Create Strong Interventions and Reduce Risk of Patient Harm

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dc.contributor.authorWolf, Laurieen
dc.contributor.authorGorman, Kristenen
dc.contributor.authorClark, Joshuaen
dc.contributor.authorGleason, Jonathanen
dc.contributor.authorParker, Sarah H.en
dc.date.accessioned2022-10-18T15:57:53Zen
dc.date.available2022-10-18T15:57:53Zen
dc.date.issued2022-05-25en
dc.date.updated2022-10-18T14:47:45Zen
dc.description.abstractObjectives: The goal of this study was to develop a systems approach for root cause analysis and action to achieve strong, sustainable interventions. The team integrated human factors principles into the design of interventions to ensure solutions maintain compatibility with human capabilities and limitations resulting in stronger solutions to prevent reoccurrence. Methods: This study was conducted at a 7-hospital health system located in southwestern Virginia. Including human factors in a new root cause analysis and action process allowed the team to design strong interventions. To assess the results of this process, a team evaluated all interventions over a 4-year period (2.75-y preimplementation and 1.4-y postimplementation). Interventions were initially blind coded and then consensus coding was executed to finalize the strength of each intervention according to the VA National Center for Patient Safety evaluation tool. Results: The new process resulted in an efficient method to address adverse events with increased staff satisfaction and interventions more resilient to human error. The number of events with strong interventions increased from 43% to 69% after implementation of the new process. Conclusions: Tailoring an event investigation process to an organizational culture is critical to implementation success. Adding human factors into the design of interventions helped facilitate intervention implementation and sustainability. Blinded ratings showed that with the integration of human factors, there was improved strength of interventions. This indicates that a focus on strong system improvement (rather than weaker individual human-based solutions) will lead to improved staff satisfaction and patient safety.en
dc.description.versionAccepted versionen
dc.format.mimetypeapplication/pdfen
dc.identifier.doihttps://doi.org/10.1097/pts.0000000000001042en
dc.identifier.eissn1549-8425en
dc.identifier.issn1549-8417en
dc.identifier.orcidWolf, Laurie [0000-0001-5875-7688]en
dc.identifier.orcidParker, Sarah [0000-0001-6333-1315]en
dc.identifier.other01209203-990000000-00039 (PII)en
dc.identifier.pmid35617630en
dc.identifier.urihttp://hdl.handle.net/10919/112190en
dc.language.isoenen
dc.publisherWolters Kluwer Healthen
dc.relation.urihttps://www.ncbi.nlm.nih.gov/pubmed/35617630en
dc.rightsIn Copyrighten
dc.rights.urihttp://rightsstatements.org/vocab/InC/1.0/en
dc.subjectComplementary and Integrative Healthen
dc.subjectPatient Safetyen
dc.subjectClinical Researchen
dc.subjectPreventionen
dc.titleImplementing Root Cause Analysis and Action: Integrating Human Factors to Create Strong Interventions and Reduce Risk of Patient Harmen
dc.title.serialJournal of Patient Safetyen
dc.typeArticle - Refereeden
dc.type.dcmitypeTexten
dc.type.otherJournal Articleen
pubs.organisational-group/Virginia Techen
pubs.organisational-group/Virginia Tech/Faculty of Health Sciencesen
pubs.organisational-group/Virginia Tech/VT Carilion School of Medicineen
pubs.organisational-group/Virginia Tech/VT Carilion School of Medicine/VTC School of Medicine - Instr Pgmsen
pubs.organisational-group/Virginia Tech/VT Carilion School of Medicine/Family and Community Medicineen
pubs.organisational-group/Virginia Tech/VT Carilion School of Medicine/Family and Community Medicine/Family and Community Medicineen
pubs.organisational-group/Virginia Tech/VT Carilion School of Medicine/VTC School of Medicine - Instr Pgms/VTC School of Medicine-Instr Pgmsen
pubs.organisational-group/Virginia Tech/VT Carilion School of Medicine/TEACH Membersen

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