Using the Human Factors Analysis and Classification System (HFACS) to understand preventable suicides in hospitals

Penelope Sweeting, Mary Finlayson, Maree Duddle, Donna Hartz

    Research output: Contribution to conferenceAbstract


    Study objectives: This study aimed to understand the individual and system failures that have contributed to preventable suicides in Australian hospitals. The second objective was to determine if HFACS-Healthcare (HFACS) would provide an effective methodology to understand the individual and system failures that result in preventable suicides. This study was the first to use HFACS to analyse suicides in hospitals and the first to access data from coronial reports. Inpatient suicide is a leading hospital sentinel event that contributes significantly to increased hospital mortality. Understanding the individual and system failures that contribute to inpatient suicide will provide an evidence base to develop effective prevention strategies to reduce the number of suicides.
    Methods: This study used a retrospective observational design using the HFACS methodology. Framework analysis was employed using HFACS as the a priori framework to analyse coronial reports of inpatient suicide from the National Coronial Information System (NCIS). HFACS framework consists of four levels of failure that guide the investigation of an adverse event: Unsafe acts, Preconditions for unsafe acts, Supervisory factors, and Organisational influences. These four levels are further divided into categories used to classify causal factors. The data were entered into an SPSS database explicitly created for the study and were analysed using descriptive statistics. The second level of analysis involved the creation of trajectories of error.
    Results: From 2009 to 2018, there were 367 cases of inpatient suicide on the NCIS database that met the study inclusion criteria. Early results indicate that HFACS is a valuable tool for elucidating causal factors for inpatient suicide. Both Individual and system failures were identified as contributing to the suicides in hospitals. The framework allowed investigators to identify recurring failures and map common trajectories of error.
    Conclusion: HFACS was used successfully to understand both individual and system causal factors that contributed to preventable hospital suicides and the common trajectories of error. Only a small number of coroners reports lacked sufficient detail to understand the contributing system failures. The results from this study provide an evidence base for developing effective strategies for reducing preventable suicides in both mental health units and in hospitals more generally.
    Original languageEnglish
    Number of pages1
    Publication statusPublished - 2021
    EventIASP 2021 31st world congress -
    Duration: 21 Sept 202124 Sept 2021


    ConferenceIASP 2021 31st world congress


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