When writing a CCFs, you are attempting to give the reader as much information as possible in a single active sentence to understand the meaning of the sentence without having to infer any subtext. The reader should be able trust that meaning of the sentence is clear and that neither knowledge of the event nor understanding of subtext is required.
General Rules for a Writing CCFs
NEVER use code labels when a writing CCFs.
ALWAYS write sentences using an active voice with a clear, explicit subject, verb, object (SVO) clause or subject, verb, complement (SVC) clause.
ALWAYS write sentence to have a singular topic, with only one idea and subject per sentence.
Specific Examples
- Exceptional Violation
Original: “The resident administered the drug without verifying it as required due to the anesthesia technician’s insistence that it was atropine.”
Revised: “Compelled by the anesthesia technician’s confident assurance and pressure, the resident made a rare decision to bypass the standard verification process, administering the drug without the usual checks.”
Revised Grammatical Changes:
Introduction of a Participial Phrase: “Compelled by the anesthesia technician’s confident assurance and under unusual pressure,” serves to set the context and mood before stating the main action. This addition gives a reason for the resident’s behavior, emphasizing the exceptional circumstances.
Use of a Past Participle: “made a rare decision to bypass” replaces the simpler past tense “administered” to highlight the deliberateness and rarity of the action.
Adding Contextual Modifiers: Terms like “rare decision” and “under unusual pressure” were used to stress the exceptional nature of the violation, which is not part of the resident’s normal behavior.
Detailing the Action: Expanding on “without verifying it” to “bypassing the standard verification process, administering the drug without the usual checks” provides more explicit detail about what the resident did wrong, emphasizing the deviation from standard procedures.
2: Routine Violation
Original: “The anesthesia technician provided the resident an unlabeled syringe, breaching medication labeling standards.”
Revised: “The anesthesia technician, following a practice not uncommon in their workflow, provided the resident with an unlabeled syringe, sidestepping the formal medication labeling standards.”
Revised Grammatical Changes:
Incorporation of an Introductory Clause: “Following a practice not uncommon in their workflow,” introduces the idea that the action is part of a pattern of behavior, without directly stating it as routine. This clause sets the stage for understanding the technician’s actions within the context of their work habits.
Subtle Language Choice: “Sidestepping the formal medication labeling standards” replaces “breaching medication labeling standards” to imply a less direct defiance of the rules, which aligns with the notion of routine violation being more about cutting corners than outright breaking rules.
Use of Commas for Clauses: Commas were used to separate the introductory clause from the main action, which helps to emphasize the context of the action as a separate piece of information that informs the reader about the nature of the violation.
- Avoiding Compound Causal Factors
The original sentence: “The anesthesia technician incorrectly prepared the wrong medication by inadvertently substituting phenylephrine for atropine.”
This sentence combines two distinct actions into a single event: the technician’s non-adherence to established rules during the preparation process, and the accidental substitution of one medication for another. To clarify the distinct nature of these actions within the HFACS framework, the sentence should divided into two parts, each emphasizing a different aspect of the event:
Routine Violation Component:
New Sentence: “Following a commonly overlooked practice within the department, the anesthesia technician, once again, prepared the medication without consulting the correct labeling guidelines.”
Explanation: This revised statement underscores the habitual nature of the technician’s behavior by indicating it’s a “commonly overlooked practice within the department” and uses “once again” to suggest repetition. By doing so, it clarifies that the action is part of a pattern of behavior (RV), rather than an isolated incident (EV). This adjustment aims to remove any ambiguity that could lead to misclassification as an Exceptional Violation, focusing on the habitual aspect and organizational tolerance implicit in Routine Violations.
By explicitly stating the behavior as a recurring practice that is overlooked within the department, the revised statement emphasizes the systemic nature of the violation, aligning it more clearly with the definition of a Routine Violation and avoiding potential confusion with the criteria for Exceptional Violations.
Skill-based Error Component:
New Sentence: “During this process, the technician, due to a lapse in attention, mistakenly confused phenylephrine with atropine.”
Explanation: This part of the narrative points out the inadvertent error—the actual confusion of two medications—characterizing it as a Skill-based Error. The emphasis here is on the unintentional nature of the mistake, arising from a momentary lapse in attention or a misunderstanding in the execution of a task, rather than a deliberate action.
In dividing the original sentence into these two new sentences, the distinction becomes clear: the first sentence addresses a behavioral issue of routine non-compliance with safety protocols (Routine Violation), while the second sentence focuses on the unintentional operational mistake made during medication preparation (Skill-based Error). This separation allows for a more nuanced analysis and categorization of the incident, aligning each part with specific elements of the HFACS framework for a clearer understanding of the underlying factors contributing to the event.