Table 5.

Tagging framework HTOPS 2018

Tag 1: Human influences (including physical and emotional behaviour)
Action	Something you do not do or should not be doing and as such is an inappropriate action e.g. a procedure like handwashing. Propping a door open when it should be shut, needle stick injury, not putting sharps in the bin properly
Complacency	FYI read patient S number from memory, taking short cuts, e.g. being in a rush to go to the next patient in a ward round
Communication	Practitioners: Cannot read handwriting, wiping the theatre board of patient data before theatre finished, poor communication between doctor and nurse, poor introduction(s), poor incomplete handover and manipulative communication Patients: Checking for ID/confirm who you are, incorrect name above the bed
Confidentiality	Leaving computers open and unattended, leaving notes unattended. Talking about patients in public spaces with colleagues, or in-front of patients
Dignity	Leaving curtains open, patient exposed, patient hurt or caused some type of distress, patient pulled backwards in a wheel chair, patient referred to by room number condition, as ‘him’ or ‘her’
Distraction	Something or someone who is distracting another, interruptions
Doing the Job	Prescribing, consenting, ordering, swab count, unlabelled specimen container, not writing clearly in the notes, using not up to date results, failure to ask about pain
Hygiene	Infection control and risk—e.g. hand washing
Language	Practitioner e.g. foreign, using jargon, abbreviations Patient e.g. foreign, deafness, disability dementia, disregard to cultural needs
Leadership	Self-awareness, awareness of others, ability to praise or admonish another. Leadership in collaborative patient-centred teams. Poor involvement of the patient in the team
Privacy	Overhearing private conversations, patient in ward hears what is being discussed at the ward desk
Professional	Decision making e.g. failure to use correct medication (lack of knowledge, missed allergy, wrong dose), medical interference e.g. unnecessary procedure test completed, not stopping a medication during surgical pathway; being unkind to a colleagues with loss of self-control; not acknowledging and listening to patient worries; and lack of patient centredness. Civility, respect and responsibility for personal health.
Situation awareness	Definition = ‘Our mental picture of what is happening around us and what is about to happen’ (Mitchell, pg. 27). See issues about an individual or about the environment around you or the systems you are using. Wrong site for surgery. Staff complaining about their work life to patients. Counting swabs in memory not aloud
Skills	Insufficient experience
Stress and fatigue	Exhausted staff who are complaining they are not having breaks and short cuts taken. Staff, volatile emotions and poor moral
Team functioning	Clearly not relating to everyone in a team. Team fails to connect with one another; missing member of the team.
Tag 2: Work environment
Equipment	No BP machine. Appropriate specialist equipment not available or working. Wet plaster left on floor, phone issues, missing items in a theatre-pack
Hardware	Furniture, physical component of a building and how it is cared for air conditioning, cleanliness, door propped open, wet floor, endoscope issues
Layout/design	Seating, inadequate meeting space, wrong bed type, no wheel chair space
Software	IT—computers and software used to support clinical activities, slow computer responses, not enough, no Wi-Fi on the ward, mouse not working, electronic prescribing issues, not logging off computer and ICE not working
Tag 3: Systems
Checking lists	Patient ID, WHO check list and check lists
Equipment	Repairs and maintenance. How failures or broken things are fixed, charging of electronic equipment
Hand overs	Lost drug keys
Insufficient staff skill mix	Too few staff or too many and inappropriate level of staff. Insufficient staff, no breaks as not enough staff, and insufficient skill mix. Change over doctor, induction and support for any staff.
Management/leadership	Ordering materials for a ward/unit. Staff rota, clinic set up, are asset up. Access for personal log in. Ordering materials and equipment. Who types us notes and who knows. Case selection for the right clinician.
Records	Documentation/forms. How notes are accessed or made available; Appointments and how they are made; multiple copies of patient notes
Transport	Ambulance and taxi issues