IDENTIFYING CAUSAL PATTERNS AND ERRORS IN ADVERSE CLINICAL INCIDENTS

摘要

This study identified precursor (PE) and associated contributing factors (CFs) of clinical incidents in health care. A random sample of 498 clinical incidents in Australia were reviewed. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks and medication issues. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs for each incident. This study highlights the need for targeted approaches to tackling clinical incidents, based on an understanding of why they occur.