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Table 4 Factors that contributed to an incident and were the target of an improvement initiative decided during morbidity and mortality conferences (N = 282)

From: Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study

Factors Number Percent
Staff 111 39.4
 Training 32 11.3
 Orientation 2 0.7
 Supervision/assistance 4 1.4
 Availability of checklists/protocols/policies 72 25.5
 Adequate staff numbers/quality 1 0.4
Organizational/environmental 91 32.3
 Matching physical environment to needs 8 2.8
 Making arrangements for access to a service 17 6.0
 Performing risk assessment/root cause analyses 2 0.7
 Current code/specifications/regulations being met 9 3.2
 Arranging ready access to protocols/policies/decision aids 31 11.0
 Improved leadership/guidance 22 7.8
 Matching of staff to tasks/skills 1 0.4
 Improving safety culture 1 0.4
Other 36 12.8
 Recommending a new practice 9 3.2
 Literature review 14 5.0
 Study of clinical cohorts 8 2.8
 Improved file/traceability 3 1.1
 Declaration to risk management unit 2 0.7
Agent/equipment 24 8.5
 Provision of equipment 20 7.1
 Regular audits 4 1.4
Patient 20 7.1
 Provision of adequate care/support 7 2.5
 Provision of patient education/training 6 2.1
 Provision of protocols/decision aid 6 2.1
 Provision of medication dispensing aid 1 0.4