Causal Codes Human
Active Errors Errors or failures that are resulting from human behavior

 

HEX

External

Human failures originating beyond the control and responsibility of the investigation organization. For a blood center, this could apply to actions by individuals in hospitals. For a transfusion service, this could apply to failures by individuals from another department such as the emergency room.

Knowledge Based

HKK

Knowledge Based Errors

The inability of an individual to apply their existing knowledge to a novel situation. Example Trained technologist unable to solve a very complex antibody identification problem.

Rule Based Behaviors

HRQ	Qualifications	A mismatch between an individuals qualification, training or education and a particular task. Example Expecting a technician to solve the same type of difficult problems as a technologist.
HRC	Coordination	A lack of task coordination within a health care team in an organization. Example Essential task not being performed because everyone thought that someone else had completed the task.
HRV	Verification	The correct and complete assessment of a situation including related conditions of the patient/donor and materials to be used before beginning the task. Example Failure to correctly identify a patient by checking the wristband.
HRI	Intervention	Failures that result from faulty task planning and execution. This would be selecting the wrong rule or procedure (planning) or executing the procedure incorrectly. Example Washing red cells by the same protocol as platelets.
HRM	Monitoring	Monitoring of process or patient status. Example Trained technologist operating an automated instrument and not realizing that a pipette that dispenses reagents is clogged.

Skill Based Behavior

HSS	Slip	Failures in the performance of highly developed skills. Example Technologist adding drops of reagent to a row of test tubes and then missing a tube or computer entry error.
HST	Tripping	Failures in whole body movement. These errors are often referred to as slipping, tripping, or falling. Examples Include dropping a blood bag and tripping over a loose tile on the floor.