[Article] Human Factors in Incident and Adverse Event Management: From Individual Error to Systemic Analysis in Patient Safety
Summary:
The occurrence of adverse events in healthcare institutions is still often attributed to individual error—an approach that is both technically limited and institutionally counterproductive. International human factors frameworks applied to incident management, such as the Swiss Cheese Model, HFACS and Just Culture, demonstrate that clinical errors most often result from the alignment of latent failures distributed across multiple layers of the care system.
In this context, human factors contribute to understanding the effects of cognitive load and fatigue on clinical decision-making, the foundational role of reporting in building a mature safety culture and the need for investigative methodologies guided by contributing factors, such as the London Protocol and RCA2.
Effective incident management requires the integration of data infrastructure, analytical methodology and organizational culture, aligned with the conditions that support the reduction of event recurrence and the measurable advancement of institutional maturity.
Key topics:
1. Human error as a symptom of systemic failures, not an isolated cause
2. Classification of contributing factors across hierarchical levels (HFACS)
3. Impact of cognitive load, fatigue and workload on clinical decision-making
4. Just Culture as the foundation for reporting and organizational learning
5. Human factors–based investigative methodologies (London Protocol, RCA, and RCA2)
6. Technology and data infrastructure as the foundation of structured incident management
Content:
Human Error as a Symptom, Not a Cause
When an adverse event occurs in a healthcare institution, the initial organizational response often focuses on identifying who made the error. This approach, while common, is both technically limited and counterproductive: it does not eliminate the conditions that made the error possible, does not strengthen the system, and, most critically, discourages reporting—the primary input for organizational learning in patient safety.
Understanding human factors in the care environment requires moving away from a punitive, individual-centered logic toward a systemic perspective grounded in evidence and internationally recognized frameworks.
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