Table 2. Operational Failure Categories, Definitions*, and Reported Examples of Pocket Card Entries.
| Category | Definition Used in Study | Examples |
|---|---|---|
| Equipment/Supplies | Missing, broken, insufficient, or inappropriate for patient and staff needs | Automated vital sign machine missing Correct size BP cuff not available IV pump not working Computers slow IV pump not working Computers slow |
| Physical Unit/Layout | Difficult for providers to observe patients, insufficient storage space, insufficient heating and cooling, cleanliness for infection control | Distance too great between rooms of assigned patients Inadequate space in patient room to accommodate equipment and family Cleanliness of unit poor Medication room layout not efficient |
| Information/Communication | Poor information flow between providers, including verbal orders, illegible written orders, excessive or redundant documentation, documentation errors, patient identification | Unable to read providers orders Physician not returning calls Lack of advance notice about patient's need for equipment/supplies Miscommunication or incomplete information across care team members |
| Staffing/Training | Insufficient orientation and in-services, staff scheduling issues, uncertainty about protocols and policies | Inadequate RN staff to address patient census No support staff to perform duties Staff unsure of how to do concurrent IV's Lack of adherence to patient care schedule No lunch break |
| Medication | Communication/documentation, equipment/supplies, administering | Medication missing or mislabeled in automated drug dispensing system Delay in response from pharmacy |
| Other | OFs that do not fit into the five categories or other breakdowns that interfere with completing the work | Lack of transportation for delivery of specimen to lab Lack of supplies requested by patient's family |
*
Instructions provided: Record problems, defined as disruptions in ability to execute a prescribed task, by using hash marks (
) to indicate the number of times a problem occurs on your shift, classified into the provided categories.