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. |