Root cause analysis of accidents with human factors analysis and classification system (HFACS) using in Imam Khomeini Hospital in Felavarjan, Isfahan, 2014

Abstract

Background and Aims: Events for domestic and foreign customers any concern on the one hand and on the other hand concern management staff and loss of capital and economic society. Hence, the necessity of analyzing events to determine root causes in order to prevent their re repetition is important. Human factors also have an important role. This study root causes of errors in order to improve safety, quality and service satisfaction makers fundamental analysis with a focus on human factors analysis and classification system is discussed. Methods: This retrospective study of quality in 2014 was carried out. Place of Imam Khomeini Felavarjan city of Isfahan. Data collection tools and semi- structured interviews with people involved in the discovery. In the first step the causes, time and place of the incident was obtained by Root Cause Analysis. Then, an analysis of accident was done based on HFACS model. Results: In this study, 5 reports of accident in Imam Khomeini hospital were analyzed by HFACS technique. This analysis showed that most of the human errors were: in the first level was Violation of the principles and clinical standards, in the second to the Poor mental state, in the third level to the inadequate supervision and failure or malfunction of a correct understanding of the problem and in the fourth level to the process of the organization. Conclusion: The study and analysis of past events and uses Human Factors Analysis and Classification System, The agreement of action plans can be developed with policies, Training of personnel, boosting the morale of responsibility, to encourage teamwork and collaboration between the part, the implementation of monitoring activities and attention to human resources as the most important strategic factors Reducing errors in repeated use of accidents and the factors that cause it to be prevented.