Certain factors may contribute to the occurrence of problems in the delivery of health care. Identification of the underlying processes can help reduce recurrent problems and guide pre-emptive interventions.

Major types of factors:

(1) cognitive-based

(2) system-based

(3) chance (random)

(4) other


Cognitive-based factors - person knew better:

(1) failure to apply basic medical or patient care

(2) failure to follow policy or protocol, took a "short cut"

(3) inattention, distraction or absent-mindedness

(4) failure to check (equipment, armband, label, etc.)

(5) broke the rules


Cognitive-based factors - person didn't know better:

(1) inexperience

(2) inadequate training

(3) inadequate or incorrect knowledge


System-based factors - at the personal or team level:

(1) communication problem

(2) poor teamwork

(3) inappropriate behavior or action


System-based factors - policy or protocol:

(1) failure to enforce a policy/protocol

(2) policy/protocol poor or deficient

(3) policy/protocol nonexistent


System-based factors - management:

(1) poor management decision

(2) pressure to proceed

(3) lack of supervision

(4) insufficient staff for the job


Other factors:

(1) lack of proper tools or equipment for task


Identification of the cause can help determine the appropriate intervention:

(1) person knew better - individual counseling and workload review

(2) person didn't know better - training and orientation

(3) personal or team level - individual or group interventions

(4) policy or protocol failure - policy and protocol maintenance and enforcement

(5) management failure - management intervention

(6) lack of equipment - review purchasing and inventory decisions

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