Table 2

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

System factorDescriptors
  • 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

CommunicationInadequate communication between care providers; inadequate information/education to patient/carer; informed consent not obtained; documentation inadequate
EquipmentNot maintained or not available (as per PIT–medical devices/equipment)
EnvironmentPhysical environment factors impaired care delivery
Policy/guidelinesNot 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 clinicianTeamwork not evident; no identified lead clinician
TransferPatient unstable/unsuitable for transfer (time/service)
SupervisionSupervision/support inadequate
WorkforceSkill mix inappropriate; orientation/induction inadequate; training/education inadequate; issues with credentialing/scope of practice; availability of senior staff
Human factor (staff)
Cognitive errorsFailure 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
  • 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 conditionsPhysically fatigued or unwell; mentally fatigued, distracted or unwell
Skill-based errorsErrors 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/disabilityCulturally and linguistically diverse
75–90 yearsEmergency presentationNo advocate/support
90 or olderFrequent flyerObese
AboriginalFrom residential careOut of hours presentation
ComorbiditiesHistory of aggressionSubstance misuse
Delirium/confusionMental illness
  • PIT, principal incident type.