Root Cause Analysis Combined with Human Factors Engineering Tools for Adverse Events Investigation in Healthcare

摘要

An important way to promote patient safety is through the investigation of adverse events (AEs). There are many available methods used in the health area to carry on an investigation and one of the most used within the healthcare area is the Root Cause Analysis (RCA). Though extremely useful, it presents some limitations. A solution to mitigate RCA limitations may be through the combination of tools available in a different method. This study presents a methodology, that combines a set of tools, derived from two methods: RCA and Human Factors Engineering (HFE). It also presents the results of the methodology application in a real case study involving an adverse event caused by a mechanic ventilator. The outcome of the study showed that the combination of HFE tools to RCA could augment the investigation scope.