Table 2 Extended Eindhoven classification model [14, 16, 17]. Distribution of root causes
From: Unplanned return presentations of older patients to the emergency department: a root cause analysis
Main category | Sub category | Code | Description | Deceased patients (n = 11) Frequencies (%) | Survival patients (n = 72) Frequencies (%) |
|---|---|---|---|---|---|
Technical | 0 | 0 | |||
External | T-ex | Technical failures beyond the control of the organisation. | |||
Design | TD | Failures to poor design of equipment etc. | |||
Construction | TC | Correct design inappropriately constructed or placed. | |||
Materials | TM | Material defects not classified under TD or TC. | |||
Organisational | 2 (10.5%) | 20 (15.2%) | |||
External | O-ex | Failures at an organisational level beyond the control and responsibility of the investigating team. | 1 (5.3%) | 2 (1.5%) | |
Transfer of knowledge | OK | Failure resulting from inadequate measures to train or supervise new or inexperienced staff. | |||
Protocols | OP | Failures relating to the quality or availability of appropriate protocols. | 2 (1.5%) | ||
Management priorities | OM | Internal management decisions which reduce focus on patient safety when faced with conflicting priorities. | 1 (5.3%) | 16 (12.1%) | |
Culture | OC | Failure due to attitude and approach of the treating organization. | |||
Human | 3 (15.8%) | 26 (19.7%) | |||
External | H-ex | Human failures beyond the control of the organisation/department | 2 (2.5%) | ||
Knowledge-based behaviour | HKK | Failure of an individual to apply their knowledge to a new clinical situation | |||
Qualifications | HRQ | An inappropriately trained individual performing the clinical task | |||
Co-ordination | HRC | A lack of task co-ordination within the healthcare team. | 7 (5.3%) | ||
Verification | HRV | Failure to correctly check and assess the situation before performing interventions | 1 (5.3%) | 6 (4.5%) | |
Intervention | HRI | Failure resulting from faulty task planning or performance | 1 (5.3%) | 11 (8.3%) | |
Monitoring | HRM | Failure to monitor the patient’s progress or condition | 1 (5.3%) | ||
Patient | Patient-related | PRF | Failures related to patient characteristics or conditions, which are beyond the control of staff and influence clinical progress | 3 (15.8%) | 16 (12.1%) |
Disease-related | DRF | Failures related to the natural progress of disease which are beyond control of patient, its carers and staff | 9 (47.4%) | 65 (49.2%) | |
X | Unclassifiable | X | 2 (10.5%) | 5 (3.8%) | |
Total | 19 | 132 |