Abstract
Reliably analyzing and aggregating the gaps that lead to adverse outcomes in patient care has been difficult. We have modified and integrated the Human Factors Analysis and Classification System (HFACS) into the patient safety analyses of events at a large university cancer hospital environment to guide the development and implementation of interventions and to reduce medical errors. HFACS provides a systematic way to represent the qualitative findings of patient safety studies in a categorical database. Consistent application of this human factors tool and successive analyses of aggregated data from medical events offers healthcare organizations an objective guide for enhancements of safety risk identification and assessment systems.
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