Results of systematic analysis of incidents associated with mechanical ventilation (n=339) and intravascular catheters (n=194)
| Root cause classification* | Mechanical ventilation (n=799 causes on 339 incident reports) | Intravascular catheters (n=434 causes on 194 incident reports) | ||||
|---|---|---|---|---|---|---|
| First level* | Second level* | n† | % | n† | % | Preventive actions‡ |
| Technical | External | 75 | 9.4 | 17 | 3.9 | Escalation§ |
| Design | 62 | 7.8 | 10 | 2.3 | Technology/equipment | |
| Construction | 10 | 1.3 | 1 | 0.2 | Technology/equipment | |
| Materials | 13 | 1.6 | 6 | 1.4 | Technology/equipment | |
| Organisational | External | 8 | 1.0 | 4 | 0.9 | Escalation |
| Transfer of knowledge | 24 | 3.0 | 15 | 3.5 | Escalation | |
| Protocols | 61 | 7.6 | 48 | 11.1 | Procedures | |
| Management priorities | 25 | 3.1 | 10 | 2.3 | Escalation | |
| Culture | 32 | 4.0 | 18 | 4.1 | Reflection | |
| Human | External | 4 | 0.5 | 2 | 0.5 | Escalation |
| Knowledge-based behaviour | 18 | 2.3 | 13 | 3.0 | Information and communication¶ | |
| Rule-based behaviour | 377 | 47.2 | 240 | 55.3 | Training | |
| Skill-based behaviour | 12 | 1.5 | 11 | 2.5 | Technology/equipment¶ | |
| Other factors | Patient-related factor | 41 | 5.1 | 29 | 6.7 | |
| Unclassifiable | 37 | 4.6 | 10 | 2.3 | ||
↵* According to the PRISMA-Medical Eindhoven Classification Model.
↵† Number of identified root causes.
↵‡ As proposed by the PRISMA-Medical Classification/Action Matrix.13
↵§ Handling the problems at a higher organisational level.
↵¶ No motivation, as motivation of personnel only is an ineffective method in the prevention of human error.13
PRISMA, Prevention Recovery Information System for Monitoring and Analysis.