Healthcare improvement often defaults to identifying who erred rather than examining why the error was possible. A more effective route is to view events through the lens of Human Factors Engineering (HFE), which emphasises how systems shape behaviour and outcomes. Five HFE principles translate this perspective into practical guidance for incident reviews, safety interventions and change programmes. They call for understanding behaviour in context, prioritising interventions that reshape the work system, encouraging unconventional solutions and recognising the interdependence of processes. Applied consistently, these principles provide a path from reaction to reflection and from retraining to system redesign.
Shift from Blame to Design
A common instinct after a safety event is to look for the person at fault. HFE redirects attention to the factors that made the undesirable outcome possible. Starting from the assumption that people come to work to do their best reframes incident analysis. The central question becomes how the process, environment or technology contributed to actions that made sense at the time but led to adverse results. This approach does not excuse mistakes, it seeks durable learning by interrogating the conditions that carry risk across shifts and settings.
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Local rationality explains why a deviation can appear reasonable within the pressures, information and tools available in the moment. To understand that logic, it is important to speak both to the person directly involved and to others in the same role. The goal is to reveal system challenges that might remain hidden in a blame-oriented review, such as excessive complexity, workload peaks, awkward interfaces or steps that conflict with real-world constraints. When these contributors are identified, improvement efforts can move beyond reminders and individual vigilance to changes that make the safer action more likely and the unsafe action harder to perform.
This mindset equips leadership teams to design incident reviews that look upstream and downstream of the visible error. It also supports redesign work that reduces reliance on perfect performance. By treating behaviour as a product of context, it becomes possible to address the factors that repeatedly create the conditions for failure, not just the latest manifestation.
Choose Interventions That Reduce Reliance on Memory
Many organisations address safety events by retraining staff or updating policies. While familiar, these measures sit low on the hierarchy of intervention effectiveness because they depend on consistent attention, memory and vigilance. When workload is high or environments are poorly designed, such dependence leaves systems vulnerable. HFE encourages moving further upstream to interventions that embed safety in the design of processes and tools.
The most effective solutions reduce the need for individual vigilance by making the correct action the path of least resistance. Forcing functions illustrate this principle by shaping actions through design. A tubing connector that prevents misconnection exemplifies how equipment can make the incorrect step impossible rather than merely discouraged. This kind of intervention does more than instruct, it changes the conditions under which work occurs, shifting safety from expectation to affordance.
Leaders designing corrective actions should ask whether proposed fixes aim to change people or the system around them. Policies and training can be necessary to establish intent and baseline competence, but they will not reliably overcome confusing interfaces, cumbersome workflows or environments that repeatedly distract staff. By prioritising interventions that streamline steps, remove ambiguity and constrain errors through design, organisations can close the gap between the way work is imagined and the way it is performed under pressure.
Think Creatively and Act as a System
Conventional solutions tend to resurface because they are familiar and straightforward to implement. HFE invites broader thinking by bringing frontline staff and representative stakeholders together to generate options without prematurely filtering ideas. Beginning from the perspective of ample resources helps teams think beyond existing constraints, unlocking concepts that can later be refined into practical, manageable solutions. This framing does not imply unlimited budgets, it creates the psychological space needed to explore possibilities before narrowing to a feasible set that still addresses root causes.
Encouraging ideas outside the norm does not require accepting them wholesale. The value lies in expanding the solution space, debating trade-offs and converging on a set of actions that frontline teams will support because they helped shape them. A collaborative process increases the likelihood that the final design will be sustainable in day-to-day operations and provide a strong return on time or financial investment.
Every change occurs within an interconnected system. Altering an intake step or staffing pattern can affect documentation, billing, throughput and clinical outcomes. Without a systems mindset, well-intended fixes risk introducing new delays, confusion or rework in adjacent processes. Effective teams map what sits upstream and downstream of the proposed change and who else depends on the affected step. Small, thoughtful modifications can produce meaningful benefits when their wider impacts are understood in advance. By anticipating interactions across the system, leaders can sequence changes to amplify positive effects and avoid shifting problems from one part of the pathway to another.
Safer care emerges when leaders direct attention from individual faults to the design of work systems. Assuming positive intent, examining behaviour through local rationality, selecting higher-leverage interventions, fostering unconventional yet collaborative solution development and recognising interdependencies provide a coherent framework for improvement. These principles support a move from reaction to reflection and from reminders to redesign. Applied to incident reviews and change programmes, they help healthcare teams build environments where the right action is the easiest action, reducing vulnerability to error and strengthening outcomes for patients and staff.
Source: ECRI
Image Credit: iStock
