Table 3:

Results of Structured Pilot Test of SAFE Loop Intervention: Contributing Work-system Factors Obtained from Incident Report Narratives

HFACS-Healthcare Tier	Contributing Factor (CF) Category	Baseline Reports	Pilot Test Reports
Organizational Influences	Organizational Climate, N (% of total CF)	0 (0%)	0 (0%)
	Operational Process, N (% of total CF)	0 (0%)	0 (0%)
	Resource Management, N (% of total CF)	0 (0%)	0 (0%)
	Subtotals	0 (0%)	0 (0%)
Supervisory Factors	Inadequate Supervision, N (% of total CF)	0 (0%)	1 (2.6%)
	Planned Inappropriate Operations, N (% of total CF)	0 (0%)	0 (0%)
	Failed to Correct Problem, N (% of total CF)	0 (0%)	1 (2.6%)
	Supervisory Violations, N (% of total CF)	0 (0%)	0 (0%)
	Subtotals	0 (0%)	2 (5.1%)
Preconditions for Unsafe Acts	Physical Environment, N (% of total CF)	0 (0%)	0 (0%)
	Tools/Technology, N (% of total CF)	2 (3.8%)	0 (0%)
	Task, N (% of total CF)	1 (1.9%)	3 (7.7%)
	Mental State, N (% of total CF)	1 (1.9%)	0 (0%)
	Physiological State, N (% of total CF)	0 (0%)	0 (0%)
	Fitness for Duty, N (% of total CF)	0 (0%)	0 (0%)
	Communication, N (% of total CF)	7 (13%)	3 (7.7%)
	Coordination, N (% of total CF)	3 (5.7%)	3 (7.7%)
	Leadership, N (% of total CF)	0 (0%)	0 (0%)
	Subtotals	14 (26%)	9 (23%)
Unsafe Acts	Decision errors, N (% of total CF)	6 (11%)	7 (18%)
	Skill-Based Errors, N (% of total CF)	26 (49%)	17 (44%)
	Perceptual Errors, N (% of total CF)	0 (0%)	0 (0%)
	Routine Violations, N (% of total CF)	0 (0%)	3 (7.7%)
	Exceptional Violations, N (% of total CF)	1 (1.9%)	0 (0%)
	Subtotals	33 (62%)	27 (69%)
	Total Contributing Factors	53 (100%)	39 (100%)
	Total Incident Reports	48	41