Frequencies (%) and types of root causes of diagnosis-related incidents at emergency departments that resulted in malpractice claims in 2001 and 2002
| Description* | n (%) | |
| Technical failures | ||
| T-Ex | Technical failures beyond the control and responsibility of the investigating organisation | 0 (0) |
| TD | Inadequate design of equipment, software or materials | 0 (0) |
| TC | Correct design of equipment that were not constructed properly | 0 (0) |
| TM | Material defects | 0 (0) |
| Organisational failures | ||
| O-EX | Organisation failures beyond the control and responsibility of the investigating organisation | 2 (1.8) |
| OK | Failures resulting form inadequate measures taken to ensure that situational or site-specific knowledge or information is transferred to all new or inexperienced staff | 0 (0) |
| OP | The quality and availability of the protocols, that is they are complicated, inaccurate, unrealistic, absent or poorly presented | 5 (4.4) |
| OM | Internal management decisions in which safety is relegated to an inferior position when there are conflicting demands or objectives | 5 (4.4) |
| OC | A collective approach to safety and risk | 1 (0.9) |
| OR | Shortcomings in or the lack of roentgen photo discussions | 12 (10.5) |
| OS | Shortcomings in the consultation of supervision by residents | 8 (7.0) |
| Human-related failures | ||
| H-EX | Human failures originating beyond the control of responsibility of the investigating organisation | 2 (1.8) |
| Knowledge based | ||
| HKK | The inability of an individual to apply his/her existing knowledge to a novel situation | 29 (25.4) |
| Rule based | ||
| HRQ | The incorrect fit between an individual's qualification, training or education, and a particular task | 16 (14.0) |
| HRC | A lack of task coordination within a healthcare team | 0(0) |
| HRV | The correct and complete assessment of a situation, including related conditions of the patient and materials to be used before beginning the task | 6 (5.3) |
| HRI | Failures that result from faulty task planning and execution | 19 (16.7) |
| HRM | Monitoring of process or patient status | 4 (3.5) |
| Skill based | ||
| HSS | Failures in the performance of highly developed skills | 0(0) |
| HST | Failures in whole body movement | 0(0) |
| Patient-related factors | ||
| PRF | Failures related to patient characteristics or actions, which are beyond the control of the health professional team and influence treatment | 5 (4.4) |
| Other | ||
| X | Failures that cannot be classified in any of the current categories | 0(0) |
| 114 (100) | ||
↵* The description is adjusted for application on diagnosis-related closed claim files.