The, A.F. (Anne Fleur) (2019) The role of human factors in the occurrence of serious adverse events in the operative process. thesis, Medicine.
Full text available on request.Abstract
Introduction – There seems to be a remaining gap in the detection of the root causes of serious adverse events and therefore the improvement of the quality and safety in healthcare by means of incident analysis has reached a plateau. Although it is known that human factors are important contributors to medical error, human factors are under-investigated in the incident analysis of serious adverse events. Therefore, the aim of this research is to investigate whether human factors are a root cause in the occurrence of serious adverse events in the operative process. Methods – Serious adverse events in the operative process reported to the Health and Youth Care Inspectorate from 01.07.2017 – 01.07.2018 were selected for this research. 278 serious adverse events were found in this category and a total of 115 serious adverse events met the predetermined inclusion criteria and were eligible for full text analysis. Data was collected on different categories including data on the patient involved, the reporting institution, the type of serious adverse event, the identified root causes of the serious adverse events and specific data on the role of human factors based on the Human Factors Investigation Tool model. Results – The researchers identified human factors as root cause of the serious adverse events in 115 (100%) serious adverse events. In 56 (48%) serious adverse events human-machine interface was identified a root cause in combination with human factors and in 5 (4.3%) serious adverse events technical factors were a root cause in combination with human factors. In all 115 serious adverse events the three components of the Human Factors Investigation model were identified including human error, situational awareness and latent factors. In none of the included serious adverse events an analysis had been performed regarding human factors and only 1 of the 115 the investigation report stated that they had used a human factors tool or literature while investigating the serious adverse event. Discussion – Human factors play an important role in the occurrence of serious adverse events and were identified in all serious adverse events included in this study. However, it is still very unusual to explicitly include human factors in incident analysis and use tools, literature or experts on human factors in this process. Healthcare organisations should be stimulated to investigate the role of human factors more systematically and thoroughly in order to create appropriate improvement measures. This will help in the improvement of the quality and safety of healthcare and prevent these serious adverse events from happening in the future. 1.2 Summary Dutch
| Item Type: | Thesis (UNSPECIFIED) |
|---|---|
| Supervisor name: | Laan, Dr. M.J. and Leistikov, Prof. Dr. I. |
| Faculty: | Medical Sciences |
| Date Deposited: | 17 Sep 2020 09:26 |
| Last Modified: | 17 Sep 2020 09:26 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/2763 |
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