From: The nature and causes of unintended events reported at ten emergency departments
Main category | Â | Subcategory | Code | Description |
---|---|---|---|---|
Latent conditions | Â | Â | Â | Â |
Technical | Â | External | T-ex | Technical failures beyond the control and responsibility of the investigating organisation. |
 |  | Design | TD | Failures due to poor design of equipment, software, labels or forms. |
 |  | Construction | TC | Correct design, which was not constructed properly or was set up in inaccessible areas. |
 |  | Materials | TM | Material defects not classified under TD or TC. |
Organisational | Â | External | O-ex | Failures at an organisational level beyond the control and responsibility of the investigating organisation, such as in another department of area (address by collaborative systems). |
 |  | Transfer of knowledge | OK | Failures resulting from inadequate measures taken to ensure that situational or domain-specific knowledge or information is transferred to all new or inexperienced staff. |
 |  | Protocols | OP | Failures relating to the quality and availability of the protocols within the department (too complicated, inaccurate, unrealistic, absent, or poorly presented). |
 |  | Management priorities | OM | Internal management decisions in which safety is relegated to an inferior position when faced with conflicting demands or objectives. This is a conflict between production needs and safety. Example: decisions that are made about staffing levels. |
 |  | Culture | OC | Failures resulting from collective approach and its attendant modes of behaviour to risks in the investigating organisation. |
Active errors | Â | Â | Â | Â |
Human | Â | External | H-ex | Human failures originating beyond the control and responsibility of the investigating organisation. This could apply to individuals in another department. |
 | Knowledge-based behaviour | Knowledge-based behaviour | HKK | The inability of an individual to apply their existing knowledge to a novel situation. Example: a trained blood bank technologist who is unable to solve a complex antibody identification problem. |
 | Rule-based behaviour | Qualifications | HRQ | The incorrect fit between an individuals training or education and a particular task. Example: expecting a technician to solve the same type of difficult problems as a technologists. |
 |  | Coordination | HRC | A lack of task coordination within a healthcare team in an organisation. Example: an essential task not being performed because everyone thought that someone else had completed the task. |
 |  | Verification | HRV | The correct and complete assessment of a situation including related conditions of the patient and materials to be used before starting the intervention. Example: failure to correctly identify a patient by checking the wristband. |
 |  | Intervention | HRI | Failures that result from faulty task planning and execution. Example: washing red cells by the same protocol as platelets. |
 |  | Monitoring | HRM | Monitoring a process or patient status. Example: a trained technologist operating an automated instrument and not realising that a pipette dispenses reagents is clogged. |
 | Skill-based behaviour | Slips | HSS | Failures in performance of highly developed skills. Example: a technologist adding drops of reagents to a row of test tubes and than missing the tube or a computer entry error. |
 |  | Tripping | HST | Failures in whole body movements. These errors are often referred to as " slipping, tripping, or falling". Examples: a blood bag slipping out of one' s hands and breaking or tripping over a loose tile on the floor. |
Other factors | Â | Â | Â | Â |
Patient related | Â | Patient related factor | PRF | Failures related to patient characteristics or conditions, which are beyond the control of staff and influence treatment. |
Other | Â | Unclassifiable | X | Failures that cannot be classified in any other category. |