title: Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital.
abstract: This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.
authors.affiliation: Australian Institute of Health Innovation, Macquarie University, Australia. Electronic address: r.mitchell@mq.edu.au.
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Mitchell
authors.affiliation: Transport and Road Safety (TARS) Research, University of New South Wales, Australia; School of Aviation, University of New South Wales, Australia.
authors.forename: Ann
authors.initials: A
authors.lastname: Williamson
authors.affiliation: School of Aviation, University of New South Wales, Australia.
authors.forename: Brett
authors.initials: B
authors.lastname: Molesworth
mesh_terms: D003951:Diagnostic Errors / Q000145:classification / Q000706:statistics & numerical data; D005260:Female; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000145:classification* / Q000706:statistics & numerical data; D008508:Medication Errors / Q000145:classification / Q000706:statistics & numerical data; D008875:Middle Aged; D061214:Patient Safety / Q000592:standards*
keywords: Classification framework; Clinical incident; Error; Patient safety