Table 3 Distribution of Recommendations by Strengths
Strength | Action | No. | %a |
|---|---|---|---|
Strong | Architectural / physical plant changes | 1 | 0% |
New devices with usability testing before purchasing | 1 | 0% | |
Engineering control, interlock, forcing functions | 2 | 0% | |
Simplify the process and remove unnecessary steps | 3 | 0% | |
Standardize on equipment or process or care maps | 10 | 1% | |
Tangible involvement and action by leadership | 1 | 0% | |
Subtotal | 18 | 2% | |
Medium | Redundancy/back-up systems | 3 | 0% |
Increase in staffing/decrease in workload | 1 | 0% | |
Software enhancements/modifications | 15 | 2% | |
Eliminate/reduce distractions | 3 | 0% | |
Checklist/cognitive aid | 8 | 1% | |
Eliminate look- and sound-alikes | 1 | 0% | |
Enhanced communication | 4 | 1% | |
Simulation training with refresher | 6 | 1% | |
Review/enhancement of policy/guideline/documentation/workflow | 39 | 5% | |
Review/re-evaluate use/appropriateness of equipment | 5 | 1% | |
Audit undertaken | 25 | 3% | |
Enhanced supervision | 6 | 1% | |
Implement a new team (frontline) | 0 | 0% | |
Subtotal | 116 | 15% | |
Weak | Double checks | 7 | 1% |
Warnings and labels | 20 | 3% | |
New procedure/memorandum/policy | 29 | 4% | |
Training and education (include counselling) | 466 | 61% | |
Additional study/analysis | 104 | 14% | |
Subtotal | 626 | 82% | |
Total (Strong + Medium + Weak) | 760 | 100% | |