Table 2

Root Cause Analysis review committee classification subset for system, human and patient factors

System factor	Descriptors
Access	Delayed or no access to service/bed/diagnostics Patient located outside clinical specialty area (outlier)
Care planning	Inadequate care plan (including end of life/advanced care directives) Patient perceived as palliative; lead team/clinician not determined Patient/carer not involved in care planning
Communication	Inadequate communication between care providers; inadequate information/education to patient/carer; informed consent not obtained; documentation inadequate
Equipment	Not maintained or not available (as per PIT–medical devices/equipment)
Environment	Physical environment factors impaired care delivery
Policy/guidelines	Not known/not available; not implemented (including if unclear or unworkable); not in line with evidence-based practise or State directives
Risk management	Known risk not mitigated (including look alike/sound alike); review/monitoring systems inadequate
Teamwork/lead clinician	Teamwork not evident; no identified lead clinician
Transfer	Patient unstable/unsuitable for transfer (time/service)
Supervision	Supervision/support inadequate
Workforce	Skill mix inappropriate; orientation/induction inadequate; training/education inadequate; issues with credentialing/scope of practice; availability of senior staff
Human factor (staff)
Cognitive errors	Failure to understand/synthesise/act appropriately on available information, including following wrong clinical pathway or not seeking appropriate assistance; mindset/narrow thinking or confined to rule-based thinking
Violations	Risky or reckless behaviour includes: intentionally exceeding scope of practice acting outside widely accepted standards (or policy) intentionally deviating from intended use (equipment, medication)
Personal conditions	Physically fatigued or unwell; mentally fatigued, distracted or unwell
Skill-based errors	Errors of omission or commission during diagnosis, planning, and treatment or general care, due to the operator not completing a particular task in line with their attained skill; lapse of attention or memory

Patient factors monitored by the Committee
Patient is/is perceived to be ‘non-compliant’	Developmentally delayed/disability	Culturally and linguistically diverse
75–90 years	Emergency presentation	No advocate/support
90 or older	Frequent flyer	Obese
Aboriginal	From residential care	Out of hours presentation
Comorbidities	History of aggression	Substance misuse
Delirium/confusion	Mental illness

PIT, principal incident type.