Table 2.
Frequency of identification for contributory factor domain by method
| Domain | Incident reporting (n=30) | Interviews and focus groups (n=10) | Observational (n=14) | Other (n=29) | ||||
| Count | % | Count | % | Count | % | Count | % | |
| Active failures | 149 | 22.6 | 22 | 9.8 | 24 | 12.6 | 110 | 18.2 |
| Communication systems | 38 | 5.8 | 12 | 5.4 | 16 | 8.4 | 66 | 10.9 |
| Design of equipment and supplies | 28 | 4.3 | 9 | 4.0 | 0.0 | 14 | 2.3 | |
| Equipment and supplies | 55 | 8.4 | 4 | 1.8 | 20 | 10.5 | 31 | 5.1 |
| External policy context | 4 | 0.6 | 0.0 | 1 | 0.5 | 4 | 0.7 | |
| Individual factors | 68 | 10.3 | 54 | 24.1 | 12 | 6.3 | 50 | 8.3 |
| Lines of responsibility | 2 | 0.3 | 4 | 1.8 | 0.0 | 9 | 1.5 | |
| Management of staff and staffing levels | 37 | 5.6 | 15 | 6.7 | 7 | 3.7 | 38 | 6.3 |
| Patient factors | 39 | 5.9 | 6 | 2.7 | 6 | 3.2 | 26 | 4.3 |
| Physical environment | 29 | 4.4 | 7 | 3.1 | 6 | 3.2 | 19 | 3.1 |
| Policy and procedures | 16 | 2.4 | 5 | 2.2 | 4 | 2.1 | 26 | 4.3 |
| Safety culture | 9 | 1.4 | 5 | 2.2 | 0.0 | 12 | 2.0 | |
| Scheduling and bed management | 2 | 0.3 | 1 | 0.4 | 3 | 1.6 | 12 | 2.0 |
| Staff workload | 10 | 1.5 | 17 | 7.6 | 4 | 2.1 | 14 | 2.3 |
| Supervision and leadership | 10 | 1.5 | 8 | 3.6 | 2 | 1.1 | 20 | 3.3 |
| Support from central functions | 23 | 3.5 | 0.0 | 9 | 4.7 | 22 | 3.6 | |
| Task characteristics | 6 | 0.9 | 6 | 2.7 | 2 | 1.1 | 6 | 1.0 |
| Team factors | 13 | 2.0 | 9 | 4.0 | 11 | 5.8 | 20 | 3.3 |
| Training and education | 17 | 2.6 | 2 | 0.9 | 5 | 2.6 | 15 | 2.5 |
| Outcome* | 9 | 1.4 | 1 | 0.4 | 25 | 13.2 | 22 | 3.6 |
| Can't code | 94 | 14.3 | 37 | 16.5 | 33 | 17.4 | 68 | 11.3 |
| Grand total | 658 | 100.0 | 224 | 100.0 | 190 | 100.0 | 604 | 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.