As over 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, SHOT 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.
Human Factors questions in SHOT Database (Dendrite)
The Human Factors Investigation Tool (HFIT) questions appear in the SHOT questionnaire, completed by SHOT reporters. These questions are designed to help reporters to consider the non-staff related factors that can contribute to the cause of an incident, such as:
- Situational Factors
- Local Working Conditions
- Organisational Factors
- External Factors
- Communication and Culture
For more information, you can access the HFIT Tuition Package; self-learning material which provides information to help understand the causal and contributory factors related to a transfusion incident from a Human Factors and Ergonomics perspective.