Table 2

Frequency of identification for contributory factor domain by method

DomainIncident reporting (n=30)Interviews and focus groups (n=10)Observational (n=14)Other (n=29)
Active failures14922.6229.82412.611018.2
Communication systems385.8125.4168.46610.9
Design of equipment and supplies284.394.00.0142.3
Equipment and supplies558.441.82010.5315.1
External policy context40.60.010.540.7
Individual factors6810.35424.1126.3508.3
Lines of responsibility20.341.80.091.5
Management of staff and staffing levels375.6156.773.7386.3
Patient factors395.962.763.2264.3
Physical environment294.473.163.2193.1
Policy and procedures162.452.242.1264.3
Safety culture91.452.20.0122.0
Scheduling and bed management20.310.431.6122.0
Staff workload101.5177.642.1142.3
Supervision and leadership101.583.621.1203.3
Support from central functions233.50.094.7223.6
Task characteristics60.962.721.161.0
Team factors132.094.0115.8203.3
Training and education172.620.952.6152.5
Can't code9414.33716.53317.46811.3
Grand total658100.0224100.0190100.0604100.0
  • * Defined as the outcome of a specific action or a behaviour that impacts on the patient. Outcome was not deemed to be a contributory factor because it simply refers to what happens subsequently to the active failure, that is, the outcome for the patient.