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The Human Factors Analysis Classification System (HFACS) Applied to Health Care
Thomas Diller, George Helmrich, Sharon Dunning, Stephanie Cox, April Buchanan and Scott Shappell
American Journal of Medical Quality published online 27 June 2013
DOI: 10.1177/1062860613491623

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491623
research-article2013
AJMXXX10.1177/1062860613491623American Journal of Medical QualityDiller et al

Article
American Journal of Medical Quality

The Human Factors Analysis

XX(X) 1–10
© 2013 by the American College of
Medical Quality
Classification System (HFACS) Reprints and permissions:
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Applied to Health Care DOI: 10.1177/1062860613491623

ajmq.sagepub.com

Thomas Diller, MD, MMM,1,2,3 George Helmrich, MD,1 Sharon Dunning, BSN, MBA,1
Stephanie Cox, RN, MPA,1 April Buchanan, MD,1,3 and Scott Shappell, PhD2,4

Abstract
In spite of efforts to improve patient safety since the 1999 report, To Error Is Human, recent studies have shown
limited progress toward preventing serious error. Most hospitals use root cause analysis as a method of serious event
investigation. The authors postulate that this method suffers from 4 problems: (a) the use of root cause analysis is
neither standardized nor reliable between organizations, (b) hospitals focus on “who” did “what” rather than on “why”
the error occurred, (c) the identified causes are often too nonspecific to develop actionable correction plans, and (d)
a standardized nomenclature does not exist to allow analysis of recurring errors across the organization. This article
describes the modification of the Human Factors Analysis Classification System based on James Reason’s theory of
error causation for use in health care. This method resolves the 4 deficiencies noted above. The authors’ experience
investigating 105 serious events over 2 years is described.

Keywords
HFACS, root cause analysis, medical error, human factors

In 1999, the Institute of Medicine published To Err Is
Human, documenting systemic patient safety concerns
within the health care industry.1 For numerous years, The
Joint Commission has required the systematic investiga-
tion of serious adverse outcomes or “sentinel events.”2
Many hospitals use root cause analysis (RCA), adapted
from the engineering disciplines, as their investigative
method.3 In spite of substantial efforts, recent findings
suggest that significant gains in patient safety have not
occurred.4-6
Concerns regarding the effectiveness of RCAs have
been discussed previously.7 The authors’ group theorizes
that the use of RCA within health care has not been opti-
mally effective because of 4 factors. First, the RCA pro-
cess itself may be flawed. In the authors’ experience, the
performance of an RCA is variable from institution to
institution with a lack of standardization and minimal
attention to interrater and intrarater reliability. This leads
to findings driven by personal agendas and the inconsis-
tent identification of systematic errors.
Second, an RCA typically focuses on “what” hap-
pened and “who” was responsible rather than on identify-
ing the true root causes defining “why” an event occurred.
This facilitates a culture of blame wherein the health care
provider is formally or informally punished rather than
identifying the impact of the environment, management,
and the organization on performance. Thus, the true
causes of the adverse event are neither identified nor cor-
rected. Worse, this leads directly to significant underre-
porting of events, further inhibiting the ability to improve
patient safety.
Third, the root causes identified in the RCA are often
nebulous and not actionable. Moreover, the human
behaviors that actually shaped the adverse event are often
not fully understood or able to be corrected. For example,
most RCAs identify poor communication as a major
cause of the adverse event. By itself, “poor communica-
tion” is ill defined and typically not actionable. If we are
to correct poor communication, we must first understand
the specific behaviors and system issues that led to the
communication breakdown (eg, assuming the receiver
1
Greenville Health System, Greenville, SC
2
Clemson University, Clemson, SC
3
University of South Carolina School of Medicine, Greenville, SC
4
Embry-Riddle Aeronautical University, Daytona Beach, FL
Corresponding Author:
Thomas W. Diller, MD, MMM, Greenville Health System,
701 Grove Road, Greenville, SC 29605.
Email: tdiller@ghs.org

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2 American Journal of Medical Quality XX(X)
understood the message, inattention by the receiver, use
of nonstandard terminology). Doing otherwise results in
nonspecific remedies that seem worthy but do not solve
the underlying problem.
Finally, RCAs typically are conducted independently
and each root cause of the adverse event is addressed with
its own unique corrective action plan, which may prove
inadequate or have unintended adverse consequences.
There often is no attempt to aggregate the root causes and
identify trends that could be addressed through culture
change or performance improvement methods.
Historically, these factors have led to corrective
actions that fail to solve the real problems driving adverse
events and, instead, focus on short-term, superficial solu-
tions.8,9 Organizations frequently find who is at fault and
punish them, change a policy or process without under-
standing its effect, or prescribe education and training
when the provider had appropriate knowledge but simply
made an error. When these corrective actions fail, we
often simply implore the providers to “try harder.” Not
surprising, the error frequently reoccurs.
Ideally, any RCA methodology used in health care
must (a) be standardized and reliable; (b) fully investi-
gate “why” an event occurred, not just “who” was respon-
sible and “what” happened; (c) provide for an in-depth
analysis of causal factors that identify specific human
behaviors and environmental factors; and (d) allow for a
standardized nomenclature that facilitates the linking
together of seemingly disparate causal chains into a
global understanding of the potential for future events to
occur. Only then can appropriate intervention strategies
be developed.
Recently, it has been proposed that health care adopt
the concepts of “reliability science” to transform current
performance into the ultrasafe environment produced in
other high-risk industries.10 The characteristics of high
reliability organizations (HRO) are well known. HROs
understand the performance of their systems, constantly
search for system defects, rigorously pursue an under-
standing of system failures, and learn to prevent or miti-
gate errors.11 For health care to become highly reliable,
there must be an improved method to detect and under-
stand near misses and adverse events.
The study of human error in the workplace is not novel
to health care. James Reason12 and others13 have sug-
gested that errors occur at 4 levels: (a) Unsafe Acts—the
actions of the operator; (b) Preconditions for Unsafe
Acts—environmental factors contributing to the error; (c)
Supervision—management actions affecting the opera-
tor; and (d) Organizational Influences—the culture, poli-
cies, and procedures of the organization that affect the
operator. According to Reason’s views, humans are inher-
ently error prone and system processes often are affected
by latent weaknesses. To counter this, organizations
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create redundant defensive barriers to prevent errors.
Although effective, each barrier has its own inherent
weaknesses that collectively degrade the quality of the
system, making it vulnerable to failure. Depicted as
“holes” within the different layers of the system, these
failures transform productive systems into failed pro-
cesses, leading to adverse events. Reason’s views of
human and system error, referred to as the “Swiss cheese”
model of error causation, have been adapted to explain
the complex failures that lead to a variety of organiza-
tional accidents.
Although Reason’s theory provides a framework for
traditional accident investigation, it lacks the specificity
to be applied within the real world. The Human Factors
Analysis and Classification System (HFACS) was devel-
oped by Shappell and Wiegmann13,14 to bridge the chasm
between theory and practice and to provide an applicable
methodology for the investigation of human accident or
incident causation. Drawing on Reason’s theory, HFACS
describes human error and system failures within his 4
levels of error causation.
The HFACS methodology originally was designed for
use within the US Navy and Marine Corps to identify com-
mon root causes among aviation-related accidents.13
Subsequently, HFACS has been adopted by the US
Department of Defence13,15,16 and commercial and general
aviation.13,14,17,18 It also has been modified and imple-
mented in a variety of nonaviation, high-risk domains
including rail19-21 and maritime shipping,22 mining,23 petro-
leum/gas,24 construction,25 and, more recently, a health
care setting.26
This article describes the further modification of
HFACS for use in a health care environment and the
results of its deployment in the authors’ health system
over the past 2 years.
HFACS
HFACS consists of causal categories under each of
Reason’s 4 levels of error causation. Each of the catego-
ries consists of nanocodes that represent specific human
behaviors or system situations that may lead to errors.
The causes of an adverse event are systematically identi-
fied and assigned to 1 or more of the nanocodes. This
rigor creates standardization of the investigative process
and allows systematic analysis of common causes of
adverse events. The HFACS methodology has been
shown to be comprehensive, diagnostic, reliable, usable,
and valid across several industries.27
Similar to Reason, HFACS describes the human fac-
tors causes of accidents at 4 tiers beginning with the
Unsafe Act itself. These are the actual actions of the
health care provider that lead to the event and are classi-
fied as an error or violation.
Diller et al
An error represents normal accepted behavior that
fails to meet the desired outcome. Three types of errors
exist. First, good decisions are based primarily on 3 con-
structs: (a) information about the patient must be known
to the provider, (b) providers must have the necessary
knowledge and training to reliably assess the informa-
tion, and (c) the provider’s experience contributes signifi-
cantly to decision making. Thus, a decision error occurs
when information, knowledge, or experience is lacking.
Second, a skill-based error occurs when providers make
a mistake while engaged in a task that is very familiar to
them. Humans frequently engage in repetitive tasks that
require minimal attention. These highly practiced and
seemingly automatic behaviors are particularly suscepti-
ble to attention or memory failures, especially if one is
interrupted or distracted during the process. These errors
also may occur when procedures and techniques are not
standardized. Finally, a perceptual error occurs when
input to 1 of the 5 senses is degraded or incomplete.
These errors often occur as providers subconsciously fill
in missing information they perceive to be correct.
Violations are the result of intentional departures from
accepted practices. The operative term here is intentional,
meaning the individual knew the accepted practice yet
chose to disregard it. There are 2 types of violations.
Routine violations tend to be habitual by nature and are
often enabled by management that tolerates the “bending
of rules.” An example is driving 5 to 10 mph over the
speed limit. Although clearly a violation of the law, most
people do it and it is often overlooked by police. It thus
becomes ingrained within the population’s culture and
habits. In health care, this often is manifested by the rou-
tine failure to follow policy or the development of a
work-around for a process. In contrast, exceptional viola-
tions represent willful behavior outside the norms and
regulations that are not condoned by management, not
engaged in by others, and not part of the individual’s
usual behavior. Although most exceptional violations are
particularly egregious, they are not considered “excep-
tional” because of their extreme nature. Rather, they are
regarded as exceptional because they are “exceptions” to
normal behavior. An example would be driving 100 mph.
The second tier of HFACS describes the Preconditions
for Unsafe Acts. Although focusing on errors allows us to
understand what happened, we learn more about “why”
the error occurred when we understand the environment
and conditions leading to the error. This level includes 3
subtypes: the condition of the operator, personnel factors,
and environmental factors.
The condition of the operator includes 3 causal cate-
gories that describe situations in which the provider is
distracted or incapable of performing the required task.
The provider may be affected by an adverse mental state,
which may occur because of excessive fatigue, stress, or
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3
distraction. An adverse physiological state exists when
the provider is acutely ill, injured, or otherwise temporar-
ily not able to safely perform the essential duties of the
job. Finally, the provider may have longer term or perma-
nent physical or mental limitations. An example is poor
eyesight. Likewise, some individuals simply do not have
the mental aptitude required to work in some areas of
health care or may not have the requisite proficiency
required to do the job. Consequently, they are limited in
the scope of work they can safely perform. Some limita-
tions may be overcome with accommodations, but others
may not.
The second subtype is personnel factors, which
includes 4 causal categories and involves provider behav-
iors contributing to the adverse event. The most common
causal category is communication and information flow
manifested by direct miscommunication between indi-
viduals or when information is unavailable, incomplete,
or inaccessible. Examples may include both the failure to
collect information and to communicate it to others.
Health care providers are expected to coordinate their
efforts; however, occasionally that does not occur and
coordination failures may result when providers work
independently rather than as a team. Planning failures
may occur when providers fail to anticipate patient needs
or create appropriate treatment plans. Fitness for duty
accounts for those instances when providers do not get
enough rest, report to work when ill, or self-medicate
with legitimate medication resulting in reduced func-
tional capabilities that may contribute to errors. These
types of issues may be categorized simultaneously as an
adverse physiologic state.
Finally, environmental factors describe the effects of
the environment on human error and also may lead to
adverse events. Two causal categories exist and include
the physical environment (eg, lighting, noise, excessive
clutter, room layout) and the technological environment,
which is affected by the design of equipment and con-
trols, display or interface characteristics, checklist design,
and automation.
The third tier of HFACS addresses the role of
Supervision in adverse events. Those at the front lines of
health care are responsible for their actions; however, in
some instances, they are the recipients of a variety of
latent failures attributable to their supervisors. This level
includes 4 subtypes: leadership, operational planning,
failure to correct known problems, and supervisory
ethics.
Failures of leadership occur when supervisors provide
inadequate training, professional guidance, or oversight
for employees. When this occurs, employees can become
isolated thereby increasing the likelihood that nonstan-
dard approaches to patient care will occur, resulting in
errors. Without proper oversight employees will resort to
4 American Journal of Medical Quality XX(X)
past practices and intuition rather than established stan-
dards of care, resulting in latent failures that go uncor-
rected, compounding over time.
Management is responsible for operational planning,
ensuring that employees are fully aware and capable of
executing the work plan. This category includes both
scheduling and the assignment of work to an individual
who is not prepared to successfully perform it.
Often, known problems exist, such as worker deficien-
cies, equipment problems, or training. If these issues are
known to the supervisor and not addressed a failure to
correct known problems occurs.
Finally, supervisors also may disregard existing rules
and regulations. An example might be to permit an indi-
vidual to perform tasks outside of the scope of his or her
licensure or qualifications. When this occurs, a supervi-
sory ethics issue exists.
The fourth and final tier of HFACS involves
Organizational Influences. Fallible decisions of upper-level
management may directly affect supervisors and the per-
sonnel they manage. Unfortunately, these organizational
influences often go unnoticed in typical RCAs. HFACS
describes 3 organizational failures: resource management,
organizational climate, and operational processes.
Resource management refers to the allocation and
maintenance of organizational resources, including
human resources (selection, training, and staffing), mon-
etary budgets, and equipment design (ergonomic specifi-
cations). Corporate decisions about how such resources
should be managed center on 2 distinct objectives: the
quality of the work and on-time, cost-effective opera-
tions. Quality may be sacrificed for cost control or effi-
ciency, leading to adverse events.
The concept of organizational climate refers to a
broad class of variables that influence worker perfor-
mance. Senior management has a responsibility to ensure
that the corporate culture is focused on patient safety.
When policies are ill defined or when they are supplanted
by unofficial rules and values, confusion abounds and
safety suffers.
Finally, operational process refers to the failure of for-
mal processes (eg, operational tempo, time pressures,
schedules), procedures (eg, performance standards, objec-
tives, documentation), and oversight within the organiza-
tion (organizational self-study and risk management).
Methods
Greenville Health System (GHS) is a 5-hospital academic
health system in the southeastern United States. A cen-
tralized risk management department oversees the inves-
tigation of serious safety events. Quality within each
clinical department is overseen by a physician vice chair
of quality (VCQ). The quality and risk management
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group modified existing HFACS nanocodes for use in a
health care setting.
The authors first used HFACS to complete a retrospec-
tive analysis of all RCAs over a 4-year period. Based on
that analysis, further modifications were made to the
nanocodes. The VCQs and risk managers were then
trained in the use of HFACS. As adverse events occurred,
risk managers performed a detailed initial investigation to
elicit the facts of the case. The VCQ(s) then facilitated a
case review with all key individuals involved in the event.
During the case review, facts and timeline were con-
firmed and discrepancies clarified. Information was then
elicited about human behaviors, policies, and systems
that contributed to the event. Initial suggestions for a cor-
rective action plan were then obtained. Because the group
was focused on why the event happened and not on who
did what, the case reviews were found to be much more
open and productive than in the past and typically com-
pleted within 1 to 2 hours. Risk managers document the
case facts and nanocodes identified during the case
review are entered into an Access database (Microsoft
Corporation, Redmond, WA).
GHS completed 98 case reviews between January
2010 and June 2012. Shappell independently reviewed
the appropriateness of the assigned nanocodes and the
overall results of the adverse events. These results were
then compared to typical results seen in other indus-
tries. On the basis of this work, he was able to validate
the use of the nanocodes and HFACS methodology
within GHS.
Results
A depiction of the HFACS framework for use in health
care is presented in Figure 1. Nineteen causal categories
and 163 nanocodes are included under the 4 tiers.
After the initial modification of HFACS, the authors
reviewed 73 RCAs completed in GHS facilities between
2005 and 2009. When the HFACS nanocodes were
applied to this retrospective data, it was found that
because the previous RCAs had been done with the
approach of determining “who” did “what” rather than
“why” the event had occurred, information required to
effectively use the HFACS nanocodes was frequently
absent or inadequate. Thus, it was concluded that
HFACS could not be reliably applied to GHS prior
adverse events.
HFACS then was applied prospectively to 105 con-
secutive adverse event cases between July 2011 and
November 2012. The percentage of each causal category
and the percentage of cases in which a causal category is
identified are contained in Table 1. Data demonstrating
the most common findings at the nanocode level for key
causal categories are described in Figures 2 through 4.
Diller et al 5

Organiza!onal
Influences

Resource Organiza!onal Organiza!onal

Management Climate Process

Supervision

Inappropriate Failure to
Inadequate Supervisory
Planned Address a Known
Supervision Viola!on
Opera!ons Problem

Precondi!ons for
Unsafe Acts

Environmental Personnel Condi!ons of

Factors Factors the Operator

Communica!on / Adverse Chronic

Physical Technological Adverse Mental
Coordina!on / Fitness for Duty Physiological Performance
Environment Environment State
Planning State Limita!on

Unsafe Act

Errors Viola!ons

Skill-Based Decision Perceptual

Rou!ne Excep!onal
Error Error Error

Figure 1. Human factors analysis classification system (HFACS) framework.

Discussion interpret, and analyze information. It has been argued that

The authors previously suggested that an effective RCA
methodology must (a) be standardized and reliable, (b) be
able to fully investigate “why” an error occurred, (c) ana-
lyze both human behavior and environmental factor
errors, and (d) provide a standardized nomenclature that
facilitates the linking together of disparate causal chains
into an understanding of the potential for future events to
occur. The authors believe HFACS meets each of these
requirements. A vast literature has demonstrated the reli-
ability of HFACS in a variety of industries.13,16,27
Humans are inherently susceptible to making errors.
These errors originate from our ability to perceive,
humans fail because of faulty perception, unwarranted
assumptions, and poor communication.28 HFACS allows
us to further define these and other specific causes of
human error. To be effective, a system of error detection
must identify both systemic and individual errors. This
framework, combined with a Just Culture model,29 allows
us to identify and correct system problems, but also hold
individuals accountable for their behaviors.
The authors found that HFACS could not be retro-
spectively applied to previous RCAs because of 3 fac-
tors. First, appropriate questions sometimes had not
been asked to identify specific behavioral causes of the

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6 American Journal of Medical Quality XX(X)

Table 1. Distribution of HFACS Causal Categories.

Total Cases With a % Cases With a
Nanocodes per % Nanocodes Nanocode From Nanocode From
Human Factors Analysis Classification System Category per Category This Category This Category

Organizational influences 96 5.6

Resource management 34 2.0 11 10.5
Organizational climate 33 1.9 24 22.9
Organizational process 29 1.7 18 17.1
Supervision 69 4.0
Inadequate supervision 26 1.5 19 18.1
Inappropriate planned operations 9 0.5 9 8.6
Failure to address known problem 14 0.8 13 12.4
Supervisory violation 20 1.2 18 17.1
Preconditions for unsafe acts 694 40.6
Environmental factors 96 5.6
Physical 52 3.0 33 31.4
Technical 44 2.6 23 21.9
Condition of operator 146 8.5
Adverse mental state 130 7.6 59 56.2
Adverse physiological state 1 0.1 1 1.0
Chronic performance limitation 15 0.9 9 8.6
Personnel factors 452 26.4
Communication, coordination, planning 449 26.2 90 85.7
Fitness for duty 3 0.2 3 2.9
Unsafe acts 852 49.8
Errors 558 32.6
Error, Skill-Based 113 6.6 57 54.3
Error, Decision 426 24.9 99 94.3
Error, Perceptual 19 1.1 16 15.2
Violations 294 17.2
Routine 270 15.8 84 80.0
Exceptional 24 1.4 12 11.4
Total 1711 105

Abbreviation: HFACS, human factors analysis and classification system.

adverse event. Second, it was not possible to retrospec-
tively determine if additional causal factors may have
been involved that were not explored in the original
RCA. Third, the higher level tiers (ie, organizational
influences, supervision) typically were not emphasized
in the previous RCA methodology. However, the
authors’ experience indicates that HFACS can be pro-
spectively applied in health care, is effective at identify-
ing both human and system errors, and lends itself
particularly well to the systematic categorization of
errors across events.
There are several key findings in the data presented
(Figure 2-4). First, communication often is cited as a sig-
nificant issue leading to adverse events.30 HFACS pro-
vides information regarding the specific human behaviors
and the effect of systems on communication errors. The
authors found that errors occur because providers do not
speak to one another effectively or because they transmit
incomplete information. Strategies targeted at specific
human behaviors affecting communication can now be
developed.
The second finding is the abundance of decision and
skilled-based errors, including inadequate risk assess-
ment, critical thinking failures, and ignoring warnings.
These are not amenable to the usual didactic training typi-
cally provided. Instead, these issues must be addressed
through simulation, reinforcement, and process improve-
ment strategies.
The third finding was particularly interesting. Most
organizations experience routine violation in approxi-
mately 25% of the adverse events (K. Berry, unpublished
data, 2010). At GHS, these occurred in 80% of the cases.
One explanation may be to assume that employees are
intentionally breaking policies. However, the authors
believe something else may be responsible. External
reviewers recently noted that GHS has “normalized vari-
ation,” meaning that its workflow and processes are not
well standardized. Thus, to get their work done, the staff
too often rely on work-arounds that may breach GHS pro-
cedures. This needs further clarification, but if true, GHS
must focus on correction of the underlying work pro-
cesses rather than blaming individuals.

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Diller et al 7

Unsafe Acts
Errors - Skill Based
Timing errors (i.e., performed task at the wrong !me) 27
Safety checklist error 25
Work or mo!on at improper speed 24
Lapse of memory/recall for all or part of a procedure 11
Poor technique (e.g., intuba!on, central line inser!on) 10
Conducted sequence item out of order 7
Habit transference with new equipment/procedure 7
Improper li"ing/posi!on for task 2

Errors - Decision
Inadequate risk assessment 75
Cri!cal-thinking failure 66
Cau!on/warning ignored or misinterpreted 65
Wrong response to urgent/emergent situa!on 50
Inadequate report provided 44
Misinterpreta!on of informa!on 39
Selected incorrect procedure 23
Failure to priori!ze task 18
Inadequate work pre-planning 16
Exceeded ability (i.e., competency) 12
Improper use of instrument, equipment, PPE, and/or materials 7
Use of defec!ve instrument, equipment, PPE, and/or materials 3
Inadequate maintenance of equipment/supplies 3
Number of Times Iden!fed
Errors - Perceptual
Misperceived pa!ent factors (e.g. strength/weight -bearing) 10
Misinterpreted/misread equipment 6

Viola!ons - Rou!ne
Viola!on of policy/procedures/standard of care 76
Failure to assess pa!ent 47
Failure to monitor pa!ent 34
Inadequate/un!mely documenta!on/communica!on 33
Distrac!ng behavior 26
Taking shortcuts (not otherwise specified) 17
Failure to follow orders 10
Disabled guards, warning systems, or safety devices 8
Use of equipment/instruments/PPE/material improperly 6
Delivery of care beyond the scope of prac!ce 6
Failed to secure equipment or materials properly 5

Viola!ons - Excep!onal
Viola!on of policy/procedures/standard of care 8
Disabled guards, warning systems, or safety devices 5
Inadequate/un!mely documenta!on/communica!on 2
Excessive risk taking 2
Failure to assess pa!ent 2
0 10 20 30 40 50 60 70 80

Figure 2. HFACS tier categories/frequency of common findings per category.

Abbreviation: HFACS, human factors analysis and classification system.

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8 American Journal of Medical Quality XX(X)

Precondi!ons for Unsafe Acts - Personnel Factors

Personnel Factors - Communica!on / Coordina!on / Planning
Inadequate communica!on between providers 82
Failure to warn/disclose cri!cal informa!on 58
Inadequate communica!on during handoff 46
Failed to use all available resources 41
Inadequate communica!on: between workgroups 41
Lack of teamwork 32
No or ineffec!ve communica!on methods 30
Confusing/conflic!ng direc!ons 21
Inadequate communica!on: staff & pa!ent/family 21
Failure in leadership (no one in charge) 18
Inaccurate informa!on provided 17 Number of Times Iden!fed
Verifica!on techniques not used 11
Lack of a plan of care 9
Inadequate communica!on: leadership/provider 7
Confusing/conflic!ng orders 6
Lack of discharge planning 5

Personnel Factors - Fitness for Duty

Inadequate rest/sleep 1
Lack of physical fitness 1
Inaccurate informa!on provided 1
0 10 20 30 40 50 60 70 80 90

Precondi!ons of Unsafe Acts - Condi!on of Operator

Condi!on of Operator - Adverse Mental State
Task overload 26
Perceived haste/pressure to complete task 18
Ina#en!on/Distrac!on 17
Complacency 14
Stress (job related) 14
Overconfidence 10
Frustra!on 7
Task fixa!on 7
Lack of confidence 6 Number of Times Iden!fed

Condi!on of Operator - Adverse Physiological State

Task overload 1

Condi!on of Operator - Chronic Performance Limita!on

Limited experience/proficiency 6
Lack of technical procedural knowledge 6
0 5 10 15 20 25 30

Figure 3. HFACS tier categories/frequency of common findings per category.

Abbreviation: HFACS, human factors analysis and classification system.

Finally, GHS, like most other organizations, relies on
comparing its staffing ratios to various national bench-
marks to plan and monitor for adequate personnel.
However, GHS data demonstrate that staffing and work-
flow issues are very likely contributing factors to adverse
events. A nanocode under organizational resources exists
for staffing but represents only 7% of GHS cases.
However, potential staffing issues appear in numerous
other categories. Adverse mental states (task overload,
work pressure, and distraction), decision and skill-based
errors (inadequate risk assessment, warning ignored, and
performing a task at the wrong time), and routine viola-
tions (failure to assess or monitor patients and taking
shortcuts) all may represent staffing issues that provide
the information to make adjustments.
Conclusions
Going forward, the authors have several future tasks.
First, the use of HFACS must be tested within other

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Diller et al 9

Precondi!ons of Unsafe Acts - Environmental

Environmental Factors - Physical
Inadequate/improper design for pa!ent care 34
Obstucted access/monitoring/vizualiza!on of pa!ent/equipment 10

Environmental Factors - Technical

Poorly designed or inadequate equipment/material/PPE/instruments 13
Inadequate/defec!ve warnings/alarms Number of Times Iden!fed
11
Unclear/out-dated policies/procedures/checklists 7
Failures of informa!on technology (so#ware and hardware issues) 5
Defec!ve equipment/material/PPE/instruments 4

0 5 10 15 20 25 30 35 40

Supervision
Inadequate Supervision
Inadequate mentoring/coaching/instruc!on 7
Inadequate oversight 7
Inadequate training 6
Failed to communicate policies/procedures 5
Failure to Address a Known Problem
Failed to ini!ate correc!ve ac!on 5
Failed to ensure problem was corrected 4
Failed to review and revise a policy/procedure 4 Number of Times Iden!fed
Inappropriate Planned Opera!ons
Failure to match staff competency with the task 4
Supervisory Viola!on
Failed to enforce policies/procedures 15
Authorized hazardous opera!on 5

0 2 4 6 8 10 12 14 16

Organiza!onal Influences
Resource Management
Inadequate staffing 21
Budgetary constraints 5
Human resources prac!ces 4
Organiza!onal Climate
Inadequate policies 13
Chain of command 7 Number of Times Iden!fed
Organiza!onal culture / values 6
Organiza!onal Processes
Strategic risk assessment 13
Corporate procedures 9

0 5 10 15 20 25

Figure 4. HFACS tier categories/frequency of common findings per category.

Abbreviation: HFACS, human factors analysis and classification system.

health care organizations to ensure that it can be applied Prior Presentations

elsewhere. Second, specific solutions must be crafted to
identify systemic problems and their effectiveness in
decreasing adverse events must be tested. Third, the
authors anticipate that organizational and supervision
errors will increase over time as they become used to
identifying them.
In conclusion, the authors believe that HFACS rep-
resents an improved RCA methodology for health care
organizations. It has the potential to identify actionable
systemic causes of error, focus specific performance
improvement efforts, and ultimately improve patient
safety.
A preliminary version of information presented in this
article was presented at the following conferences:
1. University HealthSystem Consortium Annual
Conference: Patient Safety Net User Group
Meeting; Orlando, FL; September 12, 2012.
2. American Society for Healthcare Risk Management
2012 Annual Conference; National Harbor, MD;
October 9, 2012.
3. Institute for Healthcare Improvement 24th
Annual National Forum on Quality Improvement
in Healthcare; Orlando, FL; December 11, 2012.

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10
Acknowledgment
The authors wish to thank Paris Stringfellow, PhD, Kristen
Hauck, RN, Rhonda Cox, RN, Holly Hutchins, RN, Tammie
Lord, RN, and Anna Cass, PhD, for their support of this project.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the
research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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