| Patient factors |
Illness; social, physical, or psychological conditions; relationship between patient and outpatient practice/hospital; language; articulateness; personality |
| Task factors |
How the process is structured; are protocols/standards available? |
| Individual (staff) factors |
Knowledge, skills, education/training, stress levels, health, motivation |
| Team factors |
Verbal and written communication, team structure, supervision, seeking help |
| Work/environment factors |
Staffing levels, staff qualifications, work stress, design, availability and servicing of equipment and devices, environmental conditions, noise, distractions |
| Organizational and management factors |
Resources, restrictions, structure of practice (single-handed or group practice) or structure of hospital, existence of and handling of rules, regulations, safety culture, and priorities |
| Institutional context |
Financial situation/funding of the organization, requirements imposed by the liability insurers, legal/statutory requirements (quality management) |
| Safety barriers/defenses |
Existing, reliable, and known? Might the safety barriers have prevented the event? |
