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