Qualitative analysis of factors leading to clinical incidents.

PURPOSE

The purpose of this paper is to evaluate the common themes leading or contributing to clinical incidents in a UK teaching hospital.

DESIGN/METHODOLOGY/APPROACH: A root-cause analysis was conducted on patient safety incidents. Commonly occurring root causes and contributing factors were collected and correlated with incident timing and severity.

FINDINGS

In total, 65 root-cause analyses were reviewed, highlighting 202 factors implicated in the clinical incidents and 69 categories were identified. The 14 most commonly occurring causes (encountered in four incidents or more) were examined as a key-root or contributory cause. Incident timing was also analysed; common factors were encountered more frequently during out-hours--occurring as contributory rather than a key-root cause.

PRACTICAL IMPLICATIONS

In total, 14 commonly occurring factors were identified to direct interventions that could prevent many clinical incidents. From these, an "Organisational Safety Checklist" was developed to involve departmental level clinicians to monitor practice.

ORIGINALITY/VALUE: This study demonstrates that comprehensively investigating incidents highlights common factors that can be addressed at a local level. Resilience against clinical incidents is low during out-of-hours periods, where factors such as lower staffing levels and poor service provision allows problems to escalate and become clinical incidents, which adds to the literature regarding out-of-hours care provision and should prove useful to those organising hospital services at departmental and management levels.