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Human Factors

As three quarters of all incidents reported to SHOT are related to errors, we would like to understand more about why these occur. Errors in transfusion practice may be related to workplace features. What are the human factors that contribute to errors in transfusion practice?

Patient safety incidents and errors in transfusion can lead to fatal outcomes. Effective investigation of these incidents is essential to optimise learning and take action to prevent further incidents occurring.

In 2021, we incorporated and amended The Yorkshire Contributory Factors Framework (YCFF) into our Human Factors Investigation Tool (HFIT). This Framework has an evidence base for optimising learning and addressing causes of patient safety incidents by helping SHOT, clinicians, risk managers and patient safety officers identify contributory factors incidents. It is anticipated that the HFIT questions will take around 15 minutes to complete.

The underlying aim is not to ignore individual accountability for unsafe practice, but to try to develop a more sophisticated understanding of the factors that cause incidents. These factors can then be addressed through changes and recommendations in systems, structures and local working conditions. Finding the true causes of patient safety incidents offers an opportunity to address systemic flaws effectively.

For 2023 you will note that we have also made some changes to the scale used to answer each section to simplify the process for investigators. Reporters will no longer be asked to estimate a score for causation as it has been recognised this adds additional work, and we ask that consideration to the contributory factors is given without having to assign a score.

All the questions have some further explanatory examples as ‘tool tips’ which can be viewed on the SHOT database while completing the questionnaire by hovering the mouse pointer over the question. The new questions can be viewed by clicking on the thumbnail image on the right.

SHOT recognises how difficult it can be for reporters to consider the human factors aspects of an incident, so we have prepared this self-learning material. Please click here to access the HFIT training package

We suggest watching 2 short videos produced by SHOT for more information about human factors.

SHOT would like to acknowledge the Yorkshire and Humber Improvement Academy. Creative Commons Bradford Teaching Hospitals NHS Foundation Trust for the YCFF