Implementing a human factors approach to RCA(2) : tools, processes and strategies.
The Root Cause Analysis and Action (RCA2) framework supports the implementation of sustainable systems-based improvements after investigation of patient safety events. The authors provide an overview of the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a decision tool called FACES and describe how these tools can be integrated into the RCA2 framework to foster a comprehensive, human factors analysis of patient safety events and the identification of broader system interventions.