Human Factor Analysis and Classification System (HFACS) in the Evaluation of Outpatient Medication Errors
Published at : 29 Jan 2020
Volume : IJtech
Vol 11, No 1 (2020)
DOI : https://doi.org/10.14716/ijtech.v11i1.2278
Widyanti, A., Reyhannisa, A., 2020. Human Factor Analysis and Classification System (HFACS) in the Evaluation of Outpatient Medication Errors. International Journal of Technology. Volume 11(1), pp. 167-179
| Ari Widyanti | Laboratory for Work System Design and Ergonomics, Department of Industrial Engineering, Bandung Institute of Technology (ITB), Ganesa 10, Bandung 40132, Indonesia |
| Assyifa Reyhannisa | Laboratory for Work System Design and Ergonomics, Department of Industrial Engineering, Bandung Institute of Technology (ITB), Ganesa 10, Bandung 40132, Indonesia |
Medication errors happen
frequently, meaning there is an urgent need for a systematic analysis tool to
minimize their occurrence. The aim of this study is to implement the Human
Factor Analysis and Classification System (HFACS), a tool used in human error
identification, in the case of outpatient medication errors. Nine such cases
that occurred in a pharmacy unit of an Indonesian hospital were evaluated by 40
participants, consisting of the Head of the Pharmacy Department, the heads of
units under this department, pharmacists, and staff of the Patient Safety Unit.
An HFACS questionnaire developed by the United States Department of Defense was
adopted in an Indonesian context. Each participant was asked to evaluate four
or five cases of medication errors based on items in the questionnaire. The
results show that the causes of such errors mainly lie in the layers of unsafe
acts (performance-based error), precondition of acts (mental awareness), and
organizational influence (an organizational instruction or policy which creates
an unsafe situation). Breaking down the HFACS into its sublayers, the most
prevalent causes of medication error found in this study were information
overload and fatigue, although the level of agreement among the participants
when giving HFACS ratings was low. The paper concludes by discussing the
implications of the results.
HFACS; Medication error; Outpatient; Percentage of agreement
To err is human (Kohn et al., 2000); however, when errors are
related to human life their negative consequences are crucial, which is
particularly relevant in the case of errors occurring in hospitals. Research
emphasis has been on errors in hospitals involving doctors, nurses and other hospital
or healthcare system workers in relatation to patient safety, defined as “the
prevention of harm to patients” (Institute of Medicine/IOM, in Aspden et al., 2004). Patient safety terms include
error prevention; learning from errors that do occur; and a safety culture that
involves health care professionals, organizations and patients. There are various types of error in the
healthcare system. These can be classified according to where they occurred,
incident reports, the individuals involved in the error, and system causes. One
common error is related to medication, which is usually referred to as
medication error (AHRQ, 2007), which is
defined as
“any
preventable event that may cause or lead to inappropriate medication use or
Medication
error can occur in all medication processes, including prescriptions,
transcriptions, preparation, dispensation and administration (Hussain and Kao, 2005). Most occur during the
administration stage, followed by the prescription, preparation and
transcription stages. Prescription errors refer to failures in the prescription
writing process that result in wrong instructions regarding the identity of the
recipient, the identity of the drug, or the formulation, dose, timing or
frequency. Transcription errors are related to handwriting, abbreviation use,
and unit misinterpretation, while preparation errors occur when there is a
difference between the ordered amount or concentration of a medication and what
is actually prepared and administered. Dispensation errors refer to those made
during the transfer of a prescription drug to a patient or an intermediary who
is responsible for the administration of the drug. Finally, administration
errors are related to errors in system checks, as most medications are
administered by a single nurse.
Medication
errors have endangered the health of millions of people and cost billions $ US
in extra medical costs around the world. Furthermore, Hussain
and Kao (2005) state that medication errors are important causes of
patient morbidity and mortality. Finally, the psychological effect of
medication errors on patients should also be emphasized. For all of these
reasons, medication errors have been gaining the attention of researchers and
efforts are being made to observe the causes and find ways to prevent them.
Most
research has employed a survey method; for example, a questionnaire that is
completed by nurses and pharmacists to observe the causes of medication errors.
Exploratory studies have resulted in various causes of medication errors. The Agency for Healthcare Research and
Quality (AHRQ, 2007) identified 246
medication errors reported in the United States related to human factors. These
factors regard how humans interact with their environment, including tools,
tasks and other people, which ultimately influences human performance. In
addition, Gorgich et al. (2016) explain that
human factors are not the only cause of medication errors; working and
environmental conditions, as well as organizational factors, play important
roles in determining them. In short, medication errors are multidimensional
problems, and in solving them systematic approaches and methods are needed (Gorgich et al., 2016).
Errors
and accidents in various environments and fields have been understood as a
complex sociotechnical system (Salmon et al., 2012).
Salmon et al. reviewed the three accident causation models predominantly used
in analyzing errors and accidents, namely the risk management framework, the
System-Theoretic Accident Modelling and Process Model (STAMP), and the Swiss
cheese model.
The
most frequently used model is the Swiss cheese model (Reason,
1990), which was developed into the Human Factor Analysis and
Classification System (HFACS; see Shappell and
Wiegmann, 2000), which describes the taxonomies of latent failure and
unsafe acts. HFACS is a tool for understanding and mitigating human error in
various applied settings. Although it starts with “human factors”, in fact
other related factors are considered in the model, as can be seen in Figure 1.
HFACS
has several taxonomic categories to represent layers in the system in which
errors can occur. In addition, it has the advantage of being able to link
failures across the four taxonomic levels (Salmon
et al., 2012). Originally, HFACS was designed to investigate errors
within aviation contexts. However, with some revisions and adaptations, it has
been widely used in different work conditions, such as in operating theaters
and medical settings (see Hughes et al., 2013
for an example). HFACS has also demonstrated acceptable levels of inter-rater
reliability in some studies (e.g., Li et al., 2008),
although it has also shown low levels of reliability in others (Olsen, 2011).
In
Indonesia, medication errors also occur frequently. Although there have been no
official reports from the Indonesian Ministry of Health, such errors have been
reported by several researchers in various areas and cities. For example, Purba et al. (2007) identified medication errors
in several hospitals in Jakarta, Bandung, Yogyakarta and Surabaya, with most
being missing patient information and wrong prescription. Coupled with the fact
that the growth of medicine use in Indonesia is relatively high (i.e., 12%-13% per
year), the question of medication errors should be given utmost attention.
The aim of this study is to implement HFACS, one form of sociotechnical analysis tool, in analyzing medication errors in hospital pharmacies, in particular involving outpatients in one sample Indonesian hospital. Considering that research related to medication error is limited, and the fact that HFACS has been successfully implemented in other areas of patient safety, such as identification error in surgery (Cohen et al., 2018) and in helicopter emergency medical services (Cline, 2018), it is hypothesized that HFACS can be implemented to reduce medication error. The results of the study will be valuable in providing information about the causes of medication error for hospital outpatients.
Figure 1 HFACS
Classification and Taxonomies (Dod, 2017)
In conclusion, this study provides originality in terms of
the use of HFACS to analyze medication errors. To the best of knowledge of the
authors, no previous studies have employed HFACS to analyze medication errors
involving outpatients, apart from a study conducted by Hughes
(2013), who proposed the use of the HFACS to analyze medication errors
in emergency medical services. In practice, the study has suggested meaningful
improvements for the hospital pharmacy department to minimize medication
errors. As Malhotra et al. (2012) state,
“Medicines cure, but they can also kill or cause severe adverse reactions if a
wrong medicine is administered or if the dosage is wrong. Many disasters have
occurred due to the medication errors”. Therefore, any effort to reduce
medication errors is valuable and should be undertaken urgently.
In the study, the main causes of medication error found are
information overload and fatigue. To overcome the first of these, suggestions
made include using computerized systems to reduce errors in reading the
handwriting of the doctors and in drug labeling. To minimize fatigue,
rearrangement of shift hours as well as rest time is suggested.
The
authors thank the Indonesian Ministry of Research, Technology and Higher Education
(RISTEKDIKTI) for funding this research under the PTUPT scheme, fiscal years
2018-2019.
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