Table 4.

Frequencies of different levels of the modified Human Factors Analysis and Classification System framework and corresponding textual extracts

Modified HFACS levelIncidents, n (%)References across all incidents, n (%)aIllustrative quotes
Unsafe actions99 (79)282 (40)
Errors79 (63)162 (23)
Decision-based62 (49)117 (17)Extract 1: Poor choice and timeliness of antibiotic prescription; E-39:
Mrs X was still on a course of oral co-amoxiclav ... but in breach of the requirement for [intravenous (IV)] antibiotics as set out in the sepsis pathway, IV antibiotics were not commenced until [2 days later] when IV co-amoxiclav was prescribed (the Sepsis Six pathway recommends consideration of meropenem if severe sepsis is suspected).
Action-based26 (21)36 (5)Extract 2: Insertion of the wrong lens during cataract surgery; E-52:
In line with the intraocular lens protocol, the ophthalmic fellow circled their lens choice (lens A on the biometry form). The lens [that] the ophthalmic fellow should have circled, lens D, was in the box directly adjacent to lens A.
Perceptual8 (6)9 (1)Extract 3: Wrong insulin dose; E-18:
The patient was administered an evening dose of insulin by nurse B who had checked the medication with an agency nurse. It was recorded ... that 64 units had been given. Both nurses ... misread the prescription, reading 6U as 64 ... they did not recognise that an error had occurred ... In other words what the nurse thought they saw, wasn't what was actually written because their mind constructed a different pattern with data.
Violations59 (47)120 (17)
Routine46 (37)79 (11)Extract 4: Poor record keeping; E-12:
The standard of record keeping [while] Ms Y was on ward N and prior to the caesarean section was poor, with the majority of documentation within the maternal notes being retrospective.
Exceptional30 (24)41 (6)Extract 5: Delay in reviewing test results; C-39:
There was a 12-hour delay in reviewing the x-ray.
Preconditions for unsafe acts91 (72)223 (32)
Environmental factors56 (44)92 (13)Extract 6: Overstretched emergency department (ED); D-06:
The capacity situation on both sites was full within the assessment areas. The flow throughout the organisation was poor hence patients were waiting within the ED. The requirement for monitored beds was extremely high hence the option was considered for patient to be accommodated at site M.
Extract 7: Non-compatible software; D-05:
The investigation team identified the difficulty of obtaining the [magnetic resonance imaging] images from another hospital due to non-compatible IT systems.
Extract 8: Compatibility of epidural and intravenous connections; D-33:
On the day of the incident, the nurse reported being distracted by multiple conflicting priorities and therefore was rushing to complete the request. This led to a human error of the nurse connecting the lines incorrectly ... Epidural connections are compatible with IV connectors.
Extract 9: Locally accepted workarounds; E-05:
The [surgeon] was not directly involved in the theatre checklist [World Health Organization] process for this patient, as he was scrubbing for procedure in an adjacent area. This was not challenged by the nursing team as it had been standard practice within the service.
Communication factors49 (39)80 (11)Extract 10: Lack of shared mental model; E-12:
Delays in the tasks allocated to midwives resulted in knock-on delays in Ms Z's transfer and lack of communication at handover meant the urgency for continued [fetal] heart monitoring and a medical review was not appreciated.
Extract 11: Lack of training to use communication tools; E-40:
However, although the [electronic system] is uploaded onto all of the ... computers in [the admission unit], the staff had not been instructed on the use of [it].
Patient factors27 (21)33 (5)Extract 12: Complexity and rarity of medical conditions; E-08:
The patient had an atypical presentation of [condition A]. Therefore, the respiratory physician felt that a diagnosis of [condition B] was much more likely. [Condition A] is extremely rare and so was not considered ... It is thought that colleagues of similar experience would probably have taken the same actions.
Staff wellbeing and preparedness for work8 (6)10 (1)Extract 13: Work-related stress; D-47:
The ED was experiencing very high inflow during the evening ... Additionally, a [member of staff] had been unexpectedly brought into the department in cardiac arrest ... which inevitably adversely impacted on the psychological wellbeing of the ED staff in the department.
Failure to maintain proficiency; E-37:
All clinical staff are required to complete [mental capacity assessment] e-learning training. This is essential to job role training and is linked to performance objectives at appraisal ... not all the ward team have completed this training.
Team dynamics6 (5)8 (1)Extract 15: Poor team working; D-29:
When [the patient] had severe bleeding ... the investigation team considered [that] there was a lack of team working when assessing and managing the wound problems. Surgeon F was initially trying to deal with the problem when surgeon G arrived and proceeded to attempt to control the bleeding. The patient transferred to theatre, but it is reported that surgeon F appeared to prefer to seek advice from outside the trust rather than from experienced colleagues within [the trust].
Supervisory factors40 (31)73 (10)
Inappropriate planning24 (19)36 (5)Extract 16: Poor planning leading to over-stretched patient-facing staff; D-33:
Nurse Q was supporting two other members of staff. The baby being cared for by the nurse who was being supervised by nurse Q, was ventilated ... and required a lot of additional interventions from nurse Q. At the time of being allocated to support the nurse in supernumerary period and the nurse who was undergoing additional training, nurse Q challenged the decision making but the shift leader felt the allocation was appropriate.
Inadequate oversight16 (13)26 (4)Extract 17: Poor supervision of junior staff; E-35:
During the night, [specialist registrar] C contacted consultant D on five occasions with concerns regarding Mrs K, her pain, the fall in her haemoglobin, the development of [disseminated intravascular coagulopathy] and the activation of the major haemorrhage protocol, and yet consultant D did not come into the hospital until 09.00 hours when Mrs K was already in theatre.
Failure to address a known problem6 (5)6 (1)Extract 18: Unaddressed hazards: C-32:
Prior to this incident, another patient had attempted to harm themselves by hanging in the same toilet, this attempt was unsuccessful, and patient came to no harm, but the incident was a missed opportunity to recognise the risks posed by that environment.
Supervisory violations5 (4)5 (1)Extract 19: Significant deviation from accepted practice; E-14:
The [head of service] had reviewed and approved the locum consultant's [curriculum vitae] ... however, [they] had not met and discussed the locum consultant's competency or experience in person since he had commenced employment in the trust. This was considered ... a serious service delivery failure.
Organisational factors59 (47)115 (16)
Operational process41 (33)56 (8)Extract 20: Confusing guidelines; E-49:
There was a general awareness of the [referral to treatment] policy but the policy was described ‘too difficult to follow’ and did not give clear guidance on the management of the planned waiting list ... To some extent, the difficulties between colleagues appeared to be generated by ‘system’ problems within the team including that of staff having unclear standards and not having defined responsibilities ... complicated technical guidance as well as lack of general support.
Extract 21: Patients falling through the net; E-01:
The current system relies on active engagement from the patient to make contact via the telephone and there is no evidence that the patient did this in order to book the test ... At the time of the incident there were no procedures in place to follow up patients that do not make contact with the administrative team and once removed from the waiting list there is no further contact with the patient unless they contact the team or are re-referred in.
Resource management38 (30)53 (8)Extract 22: Inadequate staffing; E-02:
Due to changes of clinicians and reduced number of clinicians within department P, the patient was being seen by different doctors at some outpatient attendances. This resulted in lack of continuity of care and probably lack of ownership of this patient's care.
Organisational culture5 (4)6 (1)Extract 23: Hierarchical practices; E-39:
The [specialist nurse on duty that day] did not consider making the referral [to the vascular team] herself. It is now known that it was at that time acceptable for direct referrals to be made via the on call vascular administration registrar by nurses when required, but this did not happen ... historically, referrals [in trust H] are only made by doctors.
Extra-organisational factors7 (6)8 (1)Extract 24: National shortage of staff with specific skills; E-44:
Due to the national shortage of radiologists, the department uses locum staff. There are known difficulties in recruiting into vacancies. This is due to the specialisation of radiologists and recruiting into those specialties. There are currently three vacancies [being advertised that] have not been filled as there has been only one applicant to one of the specialist posts.
  • aEach reference denotes an occasion where a contributory factor in the incident investigation report was identified. HFACS = Human Factors Analysis and Classification System.