ORCID Number
0000000296499269
Date of Award
Fall 12-2025
Access Type
Dissertation - Open Access
Degree Name
Doctor of Philosophy in Human Factors
Department
Human Factors and Behavioral Neurobiology
Committee Chair
Albert J. Boquet
Committee Chair Email
boque007@erau.edu
Committee Advisor
Albert J. Boquet
Committee Advisor Email
boque007@erau.edu
First Committee Member
Scott A. Shappell
First Committee Member Email
shappe88@erau.edu
Second Committee Member
Stephen Rice
Second Committee Member Email
stephen.rice2@erau.edu
Third Committee Member
Cohen, Tara
Third Committee Member Email
tara.cohen@cshs.org
College Dean
Jayathi Raghavan
Abstract
Background: Despite significant progress in patient safety, human error continues to occur at high rates in procedural settings. Traditional safety models tend to focus on retrospective incident analysis, often overlooking the systemic conditions that allow errors to occur. The Human Factors Analysis and Classification System (HFACS) offers a proactive lens to understand how and where errors emerge and is useful for identifying active and latent failures.
Objective: To evaluate the utility and reliability of the Human Factors Analysis and Classification System (HFACS) in categorizing and comparing the pattern of frequencies (events) in cardiovascular, orthopedic, trauma care, and neurosurgical procedure.
Design, Setting, and Participants: This cross-sectional observational quality improvement studies were conducted over a period of time (2015-2023). Observational data from cardiovascular surgery, orthopedic surgery, trauma care, and neurosurgery were collected and coded using HFACS. We analyzed almost 8,943 intraoperative events. Trained analysts used three coding strategies: unanimous, majority, and reconciled consensus to assess interrater reliability.
Main Outcomes and Measures: Primary outcomes included frequency and distribution of disruptions across the HFACS tiers: unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences. Fleiss’ kappa (κ) was used to determine interrater reliability.
Results: Across all specialties, most disruptions (98.25%) occurred at the preconditions for unsafe acts, identifying the presence of latent failures. In cardiovascular surgery, 49.20% were due to adverse mental states, particularly cognitive overload and stress. Physical environment issues contributed to 26.95% of disruptions, and communication, coordination & planning issues made up 12.69%.
In orthopedic surgery, 68.75% of failures were linked to communication, coordination & planning breakdowns such as poor communication, and frequent vendor interactions. Another 19.47% were related to fitness to duty, and 5.87% stemmed from physical environment stressors.
Trauma care showed a dominant failure mode in communication, coordination & planning (61.38%), followed by adverse mental states (26.71%) and fitness to duty (10.33%).
In neurosurgery, 59.42% of events were attributed to the technological environment, primarily involving intraoperative imaging, and 35.92% were tied to communication, coordination & planning.
Conclusions: HFACS is a reliable tool for categorizing human factors in diverse procedural environments. Across the four specialties, we analyzed almost 8,943 intraoperative events. 98% of disruptions weren’t caused by individual errors at all, they were rooted in latent failures, Preconditions for Unsafe Acts. Our coding showed that HFACS is not only reliable, with interrater agreement between 0.60 and 0.68, but it also consistently revealed the presence of preconditions to unsafe acts, which means that latent conditions in these four specialties drive disruptions. Findings highlight distinct latent failure profiles across specialties and underscore the importance of data driven specialty-specific safety interventions. Strategically what it means is, one-size-fits-all safety solutions won’t work in these four specialties.
Scholarly Commons Citation
Khan, Asfandyar, "A Human Factors Analysis and Classification System (HFACS) Approach to Compare Cardiovascular, Orthopedics, Trauma Care, and Neurosurgery" (2025). Doctoral Dissertations and Master's Theses. 928.
https://commons.erau.edu/edt/928
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Cardiology Commons, Neurosurgery Commons, Orthopedics Commons, Risk Analysis Commons, Trauma Commons
