Human Reliability Analysis in Healthcare

The problem of medical error in healthcare is well documented. It is estimated that tens of thousands of people die annually from preventable medical error. For over ten years, a traditional Human Reliability Analysis (HRA) technique, the Root Cause Analysis (RCA) has been used in hospitals nationwide in an attempt to explain why these errors occur and what can be done to prevent them. Still, patient safety has not improved significantly. Traditional HRA techniques are limited as analysis tools. They do not consider the context in which workers operate. They are also not based on valid psychological models that can explain human cognitive function. The Cognitive Reliability and Analysis Method (CREAM) is a HRA technique that allows analysts to examine worker actions through the context of performance-shaping factors and is based on a model of human cognition. We reviewed 87 archived RCA reports conducted by a hospital in New York State and re-analyzed 58 cases using CREAM. Despite data limitations, we discovered a possible gap between the hospital’s RCAs and the results of the CREAM analyses. The gap suggests that the CREAM identified organizational and leadership factors contributing to the cause of medical error which the RCA process either minimized or ignored.

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