A Human Factors Approach for Root Cause Analysis: A Case of Duplicate Medical Record Number

Abstract

Health care organizations have deployed the root cause analysis (RCA) method to identify factors that could have contributed to the event. An organization that appropriately takes a system approach when conducting an RCA, often discovers system issues that, if mitigated, could prevent future recurrences. Our study examined how a human factors framework could be deployed for an RCA to identify system factors associated with duplicate medical record creations. We used mixed method data collection and analysis with the Systems Engineering Initiative for Patient Safety (SEIPS) framework to guide our RCA. Results of our RCA revealed multiple system factors contributing to duplicate record creations, some of which included interactions between patients and registrars, poor system usability, poor working environment, lack of team support, and inadequate training. Changes made to the work system, based on our findings, could prevent medical record duplication in the future.