Table 2 Distribution of Root Causes by Factors
Factors by NPSA Contributory Factors Classification Framework | No. | % | Groups by the RCA Reports Review Team | No. | % |
|---|---|---|---|---|---|
Patient | 22 | 4% | Patient Factors | 22 | 4% |
Staff | 81 | 16% | Staff Behavioural Factors | 233 | 46% |
Task - policy & guideline adherence (the ‘violation’ root causes) | 152 | 30% | |||
Task – others | 25 | 5% | System Factors | 249 | 49% |
Communication | 58 | 12% | |||
Equipment | 33 | 7% | |||
Work environment | 17 | 3% | |||
Organisation | 15 | 3% | |||
Education & training | 87 | 17% | |||
Team | 14 | 3% | |||
Total | 504 | 100% | Total | 504 | 100% |