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Scholarly Commons > HCA Healthcare Journal > Vol. 7 > Iss. 5 (2026)

 

Keywords

patient safety; quality improvement; root cause analysis

Disciplines

Human Factors Psychology | Quality Improvement

Abstract

Background

Hospitals routinely collect wide-ranging data related to quality, efficiency, and clinical practice. As part of these efforts, patient safety event data are collected, compiled, and analyzed to drive process improvement.

Methods

We present a novel adaptation and application of the Department of Defense Human Factors Analysis and Classification System (HFACS) as a heuristic tool to improve the conduct of root cause analysis (RCA) sessions that follow serious patient safety events. To assess individual knowledge improvement after reviewing the heuristic tool, a 1-page summary (including a graphical image of the tool) was developed and provided to a convenience sample of staff in our facility (N = 48). Participants were asked to read over the information and then answer a 5-question survey about their knowledge of the RCA process. A Likert scale was used to assess participants’ level of knowledge prior to, and following, their exposure to the 1-page summary.

Results

Mean Likert scores increased from 2.83 to 3.42 (Δ = +0.59), reflecting improved self-reported participant perception of knowledge gained around RCA principles (paired t-test: t(47) = 4.10, P < .001) with a medium effect size (Cohen’s d = 0.59).

Conclusion

The results from this pilot study suggest that this heuristic tool may improve knowledge of RCA concepts among clinical staff. At higher levels of an organization, improved accuracy and precision of locally entered data would also improve centralized human factor data analysis to inform decision-making.

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