Objectives 

The goal of this study was to develop a systems approach for root cause analysis and action to achieve strong, sustainable interventions. The team integrated human factors principles into the design of interventions to ensure solutions maintain compatibility with human capabilities and limitations resulting in stronger solutions to prevent reoccurrence.

Methods 

This study was conducted at a 7-hospital health system located in southwestern Virginia. Including human factors in a new root cause analysis and action process allowed the team to design strong interventions. To assess the results of this process, a team evaluated all interventions over a 4-year period (2.75-y preimplementation and 1.4-y postimplementation). Interventions were initially blind coded and then consensus coding was executed to finalize the strength of each intervention according to the VA National Center for Patient Safety evaluation tool.

Results 

The new process resulted in an efficient method to address adverse events with increased staff satisfaction and interventions more resilient to human error. The number of events with strong interventions increased from 43% to 69% after implementation of the new process.

Conclusions 

Tailoring an event investigation process to an organizational culture is critical to implementation success. Adding human factors into the design of interventions helped facilitate intervention implementation and sustainability. Blinded ratings showed that with the integration of human factors, there was improved strength of interventions. This indicates that a focus on strong system improvement (rather than weaker individual human-based solutions) will lead to improved staff satisfaction and patient safety.