Journal of Pediatrics & Child Care

Research Article

A Human Factors Approach for Event Analysis in a Pediatric Intensive Care Unit

Kanji F1, Nawathe P2 and Cohen T3*

1Clinical Research Coordinator, Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, CA, USA
2Associate Professor, Pediatrics, Medical Director of Simulation, Pediatrics, Associate Director of Congenital Cardiac Intensive Care Unit, Cedars-Sinai Medical Center, Department of Pediatrics, Los Angeles, USA
3Director, Surgical Safety and Human Factors Research, Research Scientist II, and Associate Professor, Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, USA
*Address for Correspondence: Tara Cohen, Director, Surgical Safety and Human Factors Research, Research Scientist II, and Associate Professor, Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, USA, E-mail Id: Tara.cohen@cshs.org
Submission: 24 August, 2023
Accepted: 20 September 2023
 Published: 25 September 2023
Copyright: © 2023 Kanji F, et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: HFACS-Healthcare; Adverse Events; Pediatric Intensive Care; Human Factors

Abstract

Background: Medical management in the pediatric intensive care unit involves an increased risk of adverse events and near misses due to the complexity of the environment and patient acuity. Therefore, the feasibility of the Human Factors Analysis and Classification System for Healthcare was explored to identify underlying factors contributing towards adverse events and near misses in the pediatric intensive care unit.
Methods: Adverse events and near misses reported within the pediatric intensive care unit over five years were obtained from a nonprofit, tertiary care, academic medical center in Southern California. Researchers applied the Human Factors Analysis and Classification System for Healthcare framework to identify contributing factors.
Results: Using the Human Factors Analysis and Classification System for Healthcare framework, two trained human factors experts analyzed 272 events to identify contributing factors within the event narratives, resulting in identification of 340 causal factors. The top three contributing factors identified within the reports included skill-based errors (n=90, 26.47%), coordination breakdowns (n=70, 20.59%), and tools/technology breakdowns (n=49, 14.41%).
Conclusions: Adverse events and near misses in the pediatric intensive care unit can be addressed and improved with targeted human factors interventions by identifying areas of systemic weakness for the development of targeted patient safety interventions. The application of the Human Factors Analysis and Classification System for Healthcare framework to event reporting narratives bridges a gap in the understanding of safety events translating into a framework for clinical quality improvement.
Abbreviations: AE, adverse event; CF, contributing factor; HFACS-Healthcare, Human Factors Analysis and Classification System for Healthcare; MIP, medication infusion pump; NM, near-miss; PICU, pediatric intensive care unit.