Repeating Human Performance Themes in Five Health Care Adverse Events

Abstract

Public dread following well-publicized accidents energized the desire to learn from adverse events in health care. This paper summarizes an attempt to partner medical and human factors expertise to identify repeating human performance themes across adverse events. An interdisciplinary team interviewed 30 health care personnel from multiple facilities about five complex medical incidents. Ninety human performance themes were examined for each incident. Of these, ten human performance themes were identified to be salient in at least three of the incidents. Although none of these themes directly point to solutions, they increase our understanding of recurring themes across medical cases and can point to similar themes, and how they have been addressed, in other high-consequence, complex, socio-technical domains, such as aviation.

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