Human Factors Psychology Commons^™

Utilizing Human Factors To Improve Perioperative Adverse Event Investigations: An Integrated Approach, Joseph R. Keebler, Elizabeth H. Lazzara, Elizabeth Blickensderfer, Thomas Looke, Frank Rosemeier, Brittany Almon, Lou Barr, Jeffrey Kuhlman

Publications

Objective: Apply Human Factors (HF), systems engineering, and high reliability organizational principles to improve adverse event investigations in a regional hospital system. Background: Given the complexity of medicine and healthcare systems, innovative thinking is required to ensure these systems are resilient to error. Understanding the work system and its constituent parts is fundamental to understanding how errors begin and propagate. Method: This paper provides a discussion on employing a systems-based approach to improve perioperative adverse event investigations within a hospital system. Results: Data was collected across 13 investigations. The findings are summarized into 16 contributing factors, with 10 specific examples …