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Incident investigations in the NHS rely heavily on root cause analysis to identify the issues leading to the incident, this then forms the basis of the action plan to prevent further occurrences. Although the NHS Serious Incident Framework advises the use of a human factors approach to incident investigation in practice this doesn’t happen in any kind of systematic way. The application of the human factors analysis and classification system (HFACs) in the investigation of adverse events has identified that the traditional RCA investigation may not highlight the systemic issues that underpin the error. The East Midlands AHSN published the findings of the retrospective review they did as part of their safety culture programme of 125 serious incident reports using HFACS, this identified that the quality of the incident investigation and the learning identified could be improved when HFACS was applied. Feedback from the EMAHSN is that the HFACS approach is definitely valuable but is  resource intensive and would not be used for all incident investigations. 

The NENC AHSN proposal

Within the North East and North Cumbria AHSN we have an active human factors group  linked to the Health Education England Patient Safety Faculty involving clinicians from all the provider organisations. NHSI and NHSE in the region are currently reviewing how lessons are learnt from incidents with the aim of understanding why some types of incidents reoccur and how this can be addressed. Working with human factors group, colleagues from NHSI and NHSE and drawing on the experience of the EMAHSN we would like to explore how we can incorporate the HFACS approach into incident investigation tools and processes across our provider organisations, using the recognised methodology in selected serious incidents and look to develop a scaled back ‘HFACS lite’ approach as a standard element for other investigations.


  1. Interesting read

    I have worked with Suzanne Shale to develop an acute-set of codes for HFACS that has been shared widely. Very happy to share (I note Wendy mentions it above).

    It is big! However when we did the development work a key like of HFACS was the in depth codes and prescriptive nature to help investigators. A lite version would be good with the assurance that nothing was missed.


  2. Hi

    We have looked extensively at human factors and simulation training and would be really interested in this area of work


  3. Guest

    An interesting concept. I am interested in improving the use of systemic accident analysis tools in serious incident investigations and have used HFACS a couple of times for academic pieces. Anything that makes it more accessible to investigators and encourages more in depth investigations and more focused improvements would be great. Would be interested in getting involved, trialling interim versions, and the outputs from this. Have you seen Woodier and Shale's (2017) version? An extensive taxonomy!

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