Applying human factors methods to the investigation and analysis of clinical adverse events

Safety in medicine is a rapidly developing field. However, until recently i t had been unclear how the skills and tools developed by human factors prac titioners in other industries could be applied to medicine. This paper init ially outlines the quality and safety programmes healthcare systems have tr aditionally used to improve quality of care, before turning our attention t o the epidemiology of medical adverse events. The development of clinical r isk management is explained, with a focus on how human factors methods coul d be used to assist safety management in healthcare. A formal and systemati c method to investigate and analyse clinical adverse events and near misses is described, which is based on traditional human factors methodologies. T he investigation of clinical adverse events utilises a semi-structured inte rview and performance influencing factor questionnaire, whilst Reason's org anisational accident causation model is used to analyse adverse events (Rea son, J.T., 1993. The human factor in medical accidents. In: Vincent, C. (Ed .), Medical Accidents. Oxford Medical Publications, Oxford). An obstetrics case, concerning a post-partum haemorrhage is used to show how the investig ative methods can be used by a clinical risk manager to build up an accurat e and detailed description of what happened and the organisational accident causation model can be used to systematically identify why errors occurred . Finally, the applicability and necessary modifications of human factors m ethods for use in medicine are discussed. (C) 1999 Elsevier Science Ltd. Al l rights reserved.