Using the hierarchy of intervention effectiveness to improve the quality of recommendations developed during critical patient safety incident reviews

This study evaluated the Hierarch of Intervention Effective (HIE) for improving patient safety incident recommendations.

They were namely interested in increasing the proportion of system-focused recommendations. Data came from over 16 months.

Extracts:

The HIE is a human factors framework which “asserts that system-focused changes (e.g., forcing functions, automation and computerization, and simplification and standardization) are more effective at addressing contributory factors identified from patient safety incident reviews than people-focused changes (e.g., education and training, rules and policies, and reminders, checklists, and double checks)”

And “While each level of the HIE can play an important role in error prevention, people cannot be expected to compensate for weak systems”

Image 2 highlights the interventions selected for this evaluation – namely, standardising incident analysis template, earmarking time for recommendation development, use of just-in-time education and tools, HIE recommendation reviews

Via p-Charts, an “increase in system-focused recommendations from 16 to 30% over 16 months” was observed

The baseline level of 16% of systems-focused recommendations wasn’t surprising, since “as in healthcare, incident review teams gravitate to people-focused strategies to improve human performance and minimize the potential for adverse events.⁸ Humans are fallible, so there is a need to support people through system resilience improvement”

“The HIE promotes system-level change to prevent critical incidents, which other organizations may benefit from incorporating in their patient safety reviews”

Ref: Lan, M. F., Weatherby, H., Chimonides, E., Chartier, L. B., & Pozzobon, L. D. (2025, June). Using the hierarchy of intervention effectiveness to improve the quality of recommendations developed during critical patient safety incident reviews. In Healthcare Management Forum (p. 08404704251343260). Sage CA: Los Angeles, CA: SAGE Publications.