Table 2

Frequency of contributory factors domains identified, and number of patient measure of safety items developed

DomainDefinitionTimes domain identifiedIllustrative quotes from interviews
CommunicationEffectiveness of the exchange and sharing of information between staff, patients, groups, departments and services80No. I don't think they really understand anyway. But they don't talk. We were saying this before, I have got five or six different people, and they don't communicate between them, and a lot of the time that would help. (White British female, 30, physiotherapy)
Individual factors/patient factorsIndividual factors refer to characteristics of the person delivering care that may contribute in some way to active failures. Examples of such factors include inexperience, stress, personality, attitudes.62The nurses, they can be quite arrogant and they got no manners. They don't know how to talk to patients, really. (Pakistani female, 22, ENT)
Physical environmentFeatures of the physical environment that help or hinder safe practice25If your blood pressure drops they need to be able to lay you flat and there isn't enough room to move your chair down. (White British male, 64, renal)
Scheduling and bed managementAdequate scheduling to manage patient throughput minimising delays and excessive workload25All I can say to start off with is I've had five operations on my leg and I've had 13 cancellations. Now we're being not always getting into the hospital because some of the cancellations were, I would have to be …… at the weekend and then ring up Monday morning expecting to come in and then said no there's no bed you can't come in ring up next Monday morning but don't stop taking your medication. (White male, 60, ENT)
Management of staff and staffing levels /Staff workloadThe appropriate management and allocation of staff to ensure adequate skill mix and staffing levels for the volume of work
Level of activity and pressures on time during a shift
21‘Cause they're dealing with other patients. There's like six rooms with four in them, dealing with 28 patients… They're understaffed. (White male, 47, renal)
Dignity and respectAssociated with patients feeling comfortable, in control and valued13This one lady she has had a line on her chest over here and a few times they have not put the curtain around and you know they just dealt with her. I have looked over and closed my eyes and I have thought to myself that this is just not done. (Pakistani male, 39, renal)
Training and educationAccess to correct, timely and appropriate training: specific (eg, task related) and general (eg, organisation related)13When you get the trainees, they sometimes don't seem to know what they are doing, it's a worry really. (White male, 45, Renal)
Lines of responsibilityExistence of clear lines of responsibility clarifying accountability of staff members12They'll just shake your hand and say ‘hello I'm doctor so and so’ or whatever, but you don't know who they're working for or why they're there, they just keep coming in to see you, you think why has he come to see you, and who's that, they don't exactly say why they're there, that's it really! (White British Female, 54, cancer services)
Equipment and suppliesAvailability and functioning of equipment and supplies10One of the things—just on today's experience, one of the things is about the hand gel, when I came in today I noticed that the first obvious hand gel on that side was empty (White British female, 34, ENT)
Supervision and leadershipThe availability and quality of direct and local supervision and leadership10They don't know the machines—they have to go get some help, but what I'm saying is I think it's unfair on them, and they start getting a bit stressed do you know what I mean? I haven't seen it for a while, it's when we had a batch of young nurses in which they are all pretty much fine now, but at that time I just thought it was wrong and unfair on them to be left without an experienced member of staff that did know the machines (White British female, renal)
Team factorsAny factor related to the working of different professionals within a group which they may be able to change to improve patient safety8(Partner) Wasn't there before when you had the two consultants, one was asking for …. and the other one was ignoring it, things like that, Katherine's had. Two specialities clashing. (White female, 28, physiotherapy)
Support from central functionsAvailability and adequacy of central services in support the functioning of wards/ units8Yeah the practical side was good, the only downside I would say that's let this particular ward down and the patients is the pharmacy. When you come for appointments you can be 2 h waiting for the drugs to come up from the pharmacy and that's annoying for the staff, for the patients because your waiting around for 2 h before you get your treatment, which is probably a couple of hours anyway! And it's quite annoying! So you just sit in the waiting area. (White British Female, 54, cancer services).