Table 2.
Contributing and Compensatory Factors for Deviations
| Factor | Contributed To: | Compensated For: | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| Number of Delays | Number of Safety Compromises | Number of All Deviations | Number of Delays | Number of Safety Compromises | Number of All Deviations | |
|
| ||||||
| Patient | 2 (12.5%) | 7 (30.4%) | 8 (24.0%) | - | 1 (4.4%) | 1 (3.0%) |
| Anatomy | 1 (6.3%) | 3 (13.0%) | 3 (9.1%) | - | - | - |
| Physiology | 1 (6.3%) | 4 (17.4%) | 5 (15.2%) | - | 1 (4.4%) | 1 (3.0%) |
|
| ||||||
| Providers | 11 (68.8%) | 18 (78.3%) | 23 (70.0%) | 16 (100%) | 22 (95.7%) | 32 (97.0%) |
| Monitoring/Vigilance | 2 (12.5%) | 4 (17.4%) | 6 (18.2%) | 9 (56.3%) | 14 (60.9%) | 19 (57.6%) |
| Knowledge/Training | 4 (25.0%) | 6 (26.1%) | 8 (24.2%) | 1 (6.3%) | 6 (26.1%) | 6 (18.2%) |
| Decision Making | 1 (6.3%) | 2 (8.7%) | 2 (6.1%) | 4 (25.0%) | 7 (30.4%) | 9 (27.3%) |
| Leadership | 6 (37.5%) | 6 (26.1%) | 8 (24.2%) | 4 (25.0%) | 11 (47.8%) | 13 (39.4%) |
| Temperament | 1 (6.3%) | 2 (8.7%) | 2 (6.1%) | - | 2 (8.7%) | 2 (6.1%) |
| Adaptability | - | - | - | 3 (18.8%) | 3 (13.0%) | 5 (15.2%) |
| Mistakes/Slips | 2 (12.5%) | 4 (17.4%) | 4 (12.1%) | - | - | - |
| Communication | 7 (43.8%) | 7 (30.4%) | 11 (33.3%) | 10 (62.5%) | 12 (52.2%) | 20 (60.6%) |
| Coordination | 7 (43.8%) | 5 (21.7%) | 10 (30.3%) | 6 (37.5%) | 10 (43.5%) | 15 (45.5%) |
| Cooperation | - | 1 (4.4%) | 1 (3.0%) | 6 (37.5%) | 6 (26.1%) | 10 (30.3%) |
| Distraction | 1 (6.3%) | 1 (4.4%) | 1 (3.0%) | - | - | - |
| Competing Priorities | 1 (6.3%) | 2 (8.7%) | 2 (6.1%) | - | - | - |
| Status Asymmetry | 2 (12.5%) | 3 (13.0%) | 4 (12.1%) | - | - | - |
| Contingency Planning | - | - | - | 5 (31.3%) | 5 (21.7%) | 8 (24.2%) |
|
| ||||||
| Environment/Organization | 9 (56.3%) | 11 (47.8%) | 17 (52.0%) | - | - | - |
| Equipment | 3 (18.8%) | 5 (21.7%) | 7 (21.2%) | - | - | - |
| Organization | 8 (50.0%) | 8 (34.8%) | 13 (39.4%) | - | - | - |
| Communication | 7 (43.8%) | 3 (13.0%) | 8 (24.2%) | - | - | - |
| Coordination | 3 (18.8%) | 6 (26.1%) | 7 (21.2%) | - | - | - |
| Decision Making | - | 1 (4.4%) | 1 (3.0%) | - | - | - |