October 15, 2015
Human Factors Analysis
4 Health Care
Group Demonstration
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Directions
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HFACS4HC Taxonomy
CATEGORY
SUBCATEGORY
Unsafe Acts
Errors
Skill-based
Errors
Judgement and
Decisionmaking Errors
NANOCODES
Misperception
errors
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Routine
(“Bending” the
rules)
SUBCATEGORY
Violations
Exceptional
(Breaking the
rules)
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Worksheet #1

HFACS4HC
Taxonomy
Worksheet
■ Use this to determine
HFs.
■ Use the checkboxes
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Worksheet #2
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

Review sections
1, 2, 3
Complete sections
4, 5, 6.
Use to report out
your findings
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Worksheet #2

Review the following pre-filled sections
■ 1. Event Description
■ 2. Timeline
■ 3. Interviews

Complete the following sections
■ 4. HFACS4HC Findings
■ 5. Summarize Nanocodes
■ 6. Determine Action Plans

There are additional and optional sections. A template is
included on the website.
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Sample Case Demonstration
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1. Event Description
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
A 55-year-old man with a history of poorly controlled diabetes mellitus,
pancreatic insufficiency, and alcohol and cocaine abuse was found
unconscious by his neighbors. The patient had last been seen 2 days
prior and complained of dizziness, thirst, and nausea.
Emergency medical services found him unresponsive, with a Glasgow
Coma Scale score of 3. He was intubated in the field.
Upon arrival in the emergency department (ED), his pH was less than
6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg, potassium 7.8
mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42
mEq/L. A right internal jugular line was placed for access. The resident
who placed the line was relatively experienced in line placement but
was unable to confirm placement with ultrasound. Instead he used
manometry, which was not a part of the normal ED routine for line
placement.
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1. Event Description (continued)
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He ultimately chose to pull the line. Just then, another trauma patient
arrived, and the supervising attending physician left the room. The
resident opened a second line insertion kit and restarted the process.
Ultrasound was used to confirm correct placement..
Upon flushing the line, it was noted that one of the ports was not
working. The patient soon went into atrial tachycardia, which broke with
adenosine. A chest radiograph was not obtained until later, after the
patient went into ventricular fibrillation in the intensive care unit. When
the chest radiograph was finally completed, a retained wire was noted
in the pulmonary artery. The interventional radiology team was
consulted for wire removal. The retained wire likely caused a cardiac
arrest, which required shocks, chest compressions, and cooling. After
guidewire removal, the patient had no further episodes of arrhythmias,
but experienced several other serious complications during a prolonged
and stormy hospitalization
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2. Timeline
2.Timeline
Date/Day/Time
Patient’s home
ER
ER
ER
ER
ER
ER
ER
ICU
ICU
Radiology
Event Description
Emergency crew intubates in the field
Arrives in ER
ER lab work pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg,
potassium 7.8 mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42
mEq/L.
Right internal jugular line was placed
Unable to confirm placement with ultrasound. Manometry used. Line removed
Supervising attending physician left the room
The resident restarted the process. Ultrasound was used to confirm correct
placement. Upon flushing the line, it was noted that one of the ports was not
working
Patient soon went into atrial tachycardia, which broke with adenosine
Patient to intensive care. Experienced ventricular fibrillation
Chest x-ray obtained and revealed a retained wire was in the pulmonary artery.
The interventional radiology team was consulted for wire removal. The retained
wire likely caused a cardiac arrest, which required shocks, chest compressions, and
cooling. After guidewire removal, the patient had no further episodes of
arrhythmias, but experienced several other serious complications during a
prolonged and stormy hospitalization
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3. Interviews
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These usually have already been completed when the event
was investigated. They will add to the facts.
You may want to add interviews based on findings.
3.Interviews
Date
Title
Name
Attending
Dr. Charge
Resident
Dr. Joe
Other staff in room
Nurse Mary
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Notes
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Determine the HFACS4HC Nanocodes

Worksheet #1
Use this to
determine HFs.
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4. HFACS4HC Findings
Recorder notes Nanocodes on Worksheet #2
4.HFACS4HC Findings:
HFACS Category
Sub Category
 Unsafe Acts
Error: skill based
Preconditions Error
for Unsafe
Acts
Supervision
Organization
al Influences
 Unsafe Acts
Judgment and
Preconditions Decision Making
for Unsafe
Acts
Supervision
Organization
al Influences
 Unsafe Acts
Violation: Routine
Preconditions (Bending the
for Unsafe
Rules)
Acts
Supervision
Organization
al Influences


Unsafe Acts
Preconditions
for Unsafe
Acts
Supervision
Organization
al Influences
Unsafe Acts
Preconditions
for Unsafe
Acts
Supervision
Organization
al Influences
Unsafe Acts
Environmental
Factors:
Technological
Environment
Personnel Factors:
Communication/Co
ordination/
Planning
Nano Codes
Poor technique
Why?
Did not use ultrasound
to confirm placement
of first jugular line
Selected incorrect procedure
Used manometry
instead of ultrasound
Violation of
policy/procedure/standard of
care
Failed to make sure equip
could be properly used
Used manometry
instead of ultrasound
Disabled guars, warning
systems or safety devices
inadequate/defective
warnings/alarms
Failed to use all available
resources
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Use of manometry
Did not use ultrasound
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4. HFACS4HC Findings (continued)
Recorder notes Nanocodes on Worksheet #2




Unsafe Acts
Preconditions
for Unsafe
Acts
Supervision
Organization
al Influences
Unsafe Acts
Unsafe Acts
Preconditions
for Unsafe
Acts
Supervision
Organization
al Influences
Unsafe Acts
Unsafe Acts
Preconditions
for Unsafe
Acts
Supervision
Organization
al Influences
Unsafe Acts
Unsafe Acts
Preconditions
for Unsafe
Acts
Supervision
Organization
al Influences
Unsafe Acts
Inadequate
Supervision
Failed to provide adequate
oversight
Failed to identify at risk
caregiver
Supervising attending
present during first
insertion yet does not
require use of
ultrasound
Failed to communicate
policies
Failure to address
Known Problem
Failed to provide adequate
mentoring/coaching/instruct
ion
Failed to report unsafe
tendencies (allowing people
to slide when they are
wrong)
Failed to initiate corrective
action (correct known
problem)
Supervisory
Violations
Organizational
Climate
Failed to ensure problem was
corrected
Failed to enforce
policies/procedures/require
ments
Authorized hazardous
operation: Allowing unknown
hazardous operations to
continue for whatever reason
Culture that does not
condemn hazardous and/or
unethical behavior
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Supervising attending
leaves room despite
knowing resident is
planning to do a
second insertion
Supervising attending
allows use of
manometry instead of
ultrasound and leaves
room despite knowing
resident is planning to
do a second insertion
No member of team
spoke up about lack of
use of ultrasound
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5. Summary of Nanocodes
Sum the nanocodes, subcategories, categories
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6. Actions - Create an Action Plan
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Questions?
Thank You
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October 15, 2015
Human Factors Analysis
4 Health Care
Break Out Work Groups
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Purpose
 Practice
applying HFACS4HC to a case
study.
 Develop a preliminary action plan.
 Discuss how you will use HFACS4HC in
your organization.
Remember, there are no wrong answers!
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Instructions
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Assemble in your assigned group
The ECRI Facilitator will lead you to your room
Designate members of the group for the following roles:
■ A recorder
■ A presenter
■ A timekeeper

Use meeting time as follows:
■ 15 minutes-review case study and timeline (Sections 1, 2, 3)
■ 40 minutes-apply nanocodes and sum them into categories
(Sections 4 and 5)
■ 20 minutes-develop actions for nanocodes (Section 6) and
discuss how you will use HFACS4HC in your organization
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Instructions
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Only apply HFACS4HC when the information is stated, do
not make assumptions
Use index cards to record questions from the group to the
speakers panel.
On return to the full meeting, report out:
■ Section 4. What HFs nanocodes did you identify? Why?
■ Section 5. Which Categories were your top 2?
■ Section 6. What actions did you plan?
■ Your thoughts/suggestions about how you will use HFACS4HC in
your organizations?

After the reports from the break out groups, the speakers
panel will assemble for Q&A. Use index cards
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Worksheet #1

HFACS4HC
Taxonomy
Worksheet
■ Use this to determine
HFs.
■ Use the checkboxes
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Worksheet #2
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

Case Summary
Complete sections
4, 5, 6.
Use to report out
your findings
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Your breakout group color is
indicated on your name badge
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Finish Breakout at 3:45 PM
Break 3:45 – 4:00 PM
Please return promptly at: 4:00 PM
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Please follow your ECRI facilitator to
your classroom
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