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
