Table 2 A summary of the hierarchical contributing factor list for fall event reports
From: A prototype of knowledge-based patient safety event reporting and learning system
Index | Categories | Num. of Terms | Max Depth |
|---|---|---|---|
1 | Communication, other than at the time of handover/handoff | 4 | 2 |
2 | Handover/handoff | 1 | 1 |
3 | Data issues (e.g., availability, accuracy) | 4 | 2 |
4 | Environment (e.g., culture of safety, physical surroundings) | 18 | 3 |
5 | Human factors (e.g., fatigue, stress, inattention, cognitive factors) | 87 | 5 |
6 | Policies and procedures, including clinical protocols (e.g., absence, adequacy, clarity) | 6 | 3 |
7 | Staff qualifications (e.g., competence, training) | 3 | 2 |
8 | Supervision/support (e.g., clinical, managerial) | 3 | 2 |
9 | Health Information Technology (HIT) | 8 | 2 |
10 | Medications | 39 | 5 |
11 | Consequences | 10 | 3 |
12 | Admission/discharge | 3 | 2 |
13 | Event location | 5 | 2 |
14 | Therapy prior fall | 4 | 2 |