This page contains several sections relating to the Human Factors Investigation Tool and HFIT training package.
Human Factors Investigation Tool (HFIT)
The incorporation of the HFIT tool into the SHOT reporting questionnaire allows both reporters and SHOT to understand more about why the error occurred, and what were the contributory factors.
The HFIT includes questions which cover five main sections. In each of these sections there are subcategories with given examples.
Communication and culture
- Did difficulties with safety culture in your area contribute to this event
- For example patient safety awareness, fear of documentation errors, attitude to risk management, fear of speaking out, fear of reprimand
- Did written, or verbal communication issues worsen the situation
- For example poor communication between staff or departments, handover problems, lack of communication/notes, unable to read notes, inappropriate abbreviations used, unable to contact correct staff, notes availability, lack of patient identifiers or information provided
Local working conditions
- Were there challenges between workload and staff provision around the time of the event
- For example unusually high workload, insufficient staff, staff sickness
- Were there any challenges or barriers related to team function in relation to leadership, supervision and roles within the team
- For example inappropriate delegation, unclear responsibilities, remote supervision, inappropriate skill mix
- Were there any difficulties obtaining the right equipment and/or supplies at the right time
- For example unavailable blood component or product, equipment not working, equipment not available, inadequate maintenance, supplies issues
Situational factors
- Does the cause of this event include any challenges or barriers in team function
- For example conflicting team goals, lack of respect for colleagues, poor delegation, absence of feedback
- Were there any reasons this event was more likely to occur with the particular staff involved
- For example fatigue, stress, rushed, distraction, inexperience, insufficient training
- Did challenges or barriers in task features make the event more likely
- For example unfamiliar task, difficult task, monotonous task
- Were there reasons that this event was more likely to occur to this particular patient
- For example language barrier, uncooperative, complex medical history, emergency transfusion, critically unwell, unable to confirm identity
Organisational factors
- Did the environment hinder work in any way
- For example poor layout, lack of space, excessive noise/heat/cold, poor patient visibility or access, poor lighting
- Were there difficulties in other departments that contributed
- For example appropriate support from IT, HR, porters, estates or clinical services (such as radiology, phlebotomy, pharmacy, biochemistry, blood bank, microbiology, physiotherapy, medical or surgical sub-specialities, theatres, GP, ambulances, theatre scheduling)
- Did organisational pressures play a role in the event
- For example delay in the provision of care, transfer between care settings, difficulties finding a bed, lack of out of hours support, patient an outlier in a different speciality
- Were there issues or gaps with staff skill or knowledge
- For example inadequate training, no protected time for teaching, training not standardised, no regular updates
- Were there any issues with policies and procedures
- For example were they clear, accurate, in date, easy to follow, reflect work as done
External factors
- Were there any characteristics about the equipment that were unhelpful
- For example confusing equipment design , equipment not fit for purpose, similar drug or component names or appearance, ambiguous labelling and packaging, IT features
- Have any national policies or high-level regulatory issues influenced this event
- For example commissioned resources, blood supply issues and alerts, national medical/nursing standards, 4 hour Emergency Department target, accreditation/ regulatory inspection issue, national safety alerts/notices
Summary questions
- If you could change one thing to make this incident less likely to happen again, what would it be?
- HFIT also asks about actions taken as a result of the event, and for the reporter to access the strength of the effectiveness of the intervention, selecting from the following drop down boxes:
- Forcing Functions e.g. physical change or control to force correct action
- Automation and computerisation
- Simplification and standardisation
- Rules and policies
- Reminders, checklists and double checks
- Education and training
Human Factors Training Package
SHOT recognises how difficult it can be for reporters to score the human factors aspects of an incident, and have prepared this self-learning material. Please click here to access the HFIT training package.
