Skip to main content

Advertisement

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