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Table 3 Distribution of Recommendations by Strengths

From: Our first review: an evaluation of effectiveness of root cause analysis recommendations in Hong Kong public hospitals

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%
  1. a Discrepancies in display results due to round-off