Table 1.
Frequency of identification for contributory factor domains by setting
| Domain | Anaesthesia (n=7) | General hospital (n=30) | Intensive care (n=19) | Surgery (n=16) | Other (n=11) | Totals | ||||||
| Count | % | Count | % | Count | % | Count | % | Count | % | Count | % | |
| Active failures | 17 | 16.2 | 79 | 13.5 | 112 | 29.0 | 51 | 14.0 | 46 | 19.3 | 305 | 18.2 |
| Communication systems | 2 | 1.9 | 47 | 8.0 | 35 | 9.1 | 33 | 9.1 | 15 | 6.3 | 132 | 7.9 |
| Design of equipment and supplies | 1 | 1.0 | 16 | 2.7 | 9 | 2.3 | 8 | 2.2 | 17 | 7.1 | 51 | 3.0 |
| Equipment and supplies | 16 | 15.2 | 20 | 3.4 | 31 | 8.0 | 33 | 9.1 | 10 | 4.2 | 110 | 6.6 |
| External policy context | 0.0 | 7 | 1.2 | 0.0 | 0.0 | 2 | 0.8 | 9 | 0.5 | |||
| Individual factors | 16 | 15.2 | 74 | 12.7 | 41 | 10.6 | 37 | 10.2 | 16 | 6.7 | 184 | 11.0 |
| Lines of responsibility | 0.0 | 9 | 1.5 | 1 | 0.3 | 4 | 1.1 | 1 | 0.4 | 15 | 0.9 | |
| Management of staff and staffing levels | 3 | 2.9 | 36 | 6.2 | 23 | 6.0 | 23 | 6.3 | 12 | 5.0 | 97 | 5.8 |
| Patient factors | 2 | 1.9 | 43 | 7.4 | 19 | 4.9 | 9 | 2.5 | 4 | 1.7 | 77 | 4.6 |
| Physical environment | 5 | 4.8 | 15 | 2.6 | 16 | 4.1 | 16 | 4.4 | 9 | 3.8 | 61 | 3.6 |
| Policy and procedures | 0.0 | 27 | 4.6 | 15 | 3.9 | 4 | 1.1 | 5 | 2.1 | 51 | 3.0 | |
| Safety culture | 0.0 | 10 | 1.7 | 4 | 1.0 | 4 | 1.1 | 8 | 3.4 | 26 | 1.6 | |
| Scheduling and bed management | 0.0 | 7 | 1.2 | 0.0 | 9 | 2.5 | 2 | 0.8 | 18 | 1.1 | ||
| Staff workload | 1 | 1.0 | 23 | 3.9 | 9 | 2.3 | 5 | 1.4 | 7 | 2.9 | 45 | 2.7 |
| Supervision and leadership | 4 | 3.8 | 17 | 2.9 | 7 | 1.8 | 8 | 2.2 | 4 | 1.7 | 40 | 2.4 |
| Support from central functions | 1 | 1.0 | 17 | 2.9 | 9 | 2.3 | 13 | 3.6 | 14 | 5.9 | 54 | 3.2 |
| Task characteristics | 1 | 1.0 | 5 | 0.9 | 6 | 1.6 | 4 | 1.1 | 4 | 1.7 | 20 | 1.2 |
| Team factors | 1 | 1.0 | 13 | 2.2 | 6 | 1.6 | 31 | 8.5 | 2 | 0.8 | 53 | 3.2 |
| Training and education | 1 | 1.0 | 19 | 3.3 | 8 | 2.1 | 3 | 0.8 | 8 | 3.4 | 39 | 2.3 |
| Outcome* | 7 | 6.7 | 9 | 1.5 | 1 | 0.3 | 27 | 7.4 | 13 | 5.5 | 57 | 3.4 |
| Can't code | 27 | 25.7 | 91 | 15.6 | 34 | 8.8 | 41 | 11.3 | 39 | 16.4 | 232 | 13.8 |
| Grand total | 105 | 100.0 | 584 | 100.0 | 386 | 100.0 | 363 | 100.0 | 238 | 100.0 | 1676 | 100.0 |
*
Defined as the outcome of a specific action or a behaviour that impacts on the patient. Outcome was not deemed to be a contributory factor because it simply refers to what happens subsequently to the active failure, that is, the outcome for the patient.