Skip to main content

Table 1 Description of categories of the Eindhoven Classification Model: PRISMA-medical version[19, 20]

From: The nature and causes of unintended events reported at ten emergency departments

Main category

 

Subcategory

Code

Description

Latent conditions

    

Technical

 

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

 

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

    

Human

 

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

    

Patient related

 

Patient related factor

PRF

Failures related to patient characteristics or conditions, which are beyond the control of staff and influence treatment.

Other

 

Unclassifiable

X

Failures that cannot be classified in any other category.