Includes

• Unit budget

• Facility budget

Excludes

Includes

• delegation of task or care to inadequately prepared staff;

  inappropriate staff assignment;

  staff assigned to the wrong unit or patient;

  temporarily assigned internal facility staff (e.g., relief, float, resource, travelers)

Excludes

• lack of staff understanding, technical skill, clinical knowledge (select “Staff competencies”);

  inadequate or disproportionate staffing levels,

  chronic or acute staffing problems,

  insufficient numbers and/or types of staff for patient care needs (select “Staffing levels”)

  N only: frequent changes in facility or unit staff (select “Staffing turnover”)

Includes

• inadequate supervision during learning process (e.g., walking away from a resident preforming their second central line);

• inadequate supervision according to facility policy (e.g., anesthesiologist fails to supervise a CRNA according to policy)

Excludes

• supervision of non-clinical processes (select “Managerial supervision”);

  inadequate staff competencies (select “Staff competencies”);

  tasks performed by untrained or inadequately trained staff (select “Job orientation or training”)

Includes

• lack of acknowledgment of the high-risk nature of an organization's activities;

• an environment where individuals are unable to report errors or near misses without fear of reprimand or punishment;

• collaboration across ranks is not encouraged to seek solution to patient safety problems;

• lack of organizational commitment of resources to address safety concerns;

• behavior or behaviors from providers or staff that undermine a culture of safety, including overt actions such as verbal outbursts and physical threats, as well as passive activities, such as refusing to perform tasks or uncooperative attitudes (e.g., reluctance or refusal to answer questions, return phone calls or pages, condescending language, impatience with questions or consistently arriving late without regard to team or patient)

Excludes

Includes

• staff were unaware of how to make an internal report, or what should be reported; internal reporting is not consistent

Excludes

• facility does not have an internal incident reporting system, or does not analyze internal reports to identify areas of risk (select “Systems to identify risk”)

Includes

• routine job training;

  in-service education;

  competency training;

  job orientation;

  availability of training programs

Excludes

• lack of staff understanding, technical skill, clinical knowledge (select “Staff competencies”)

Includes

• general manager supervisory functions (e.g., attendance, accountability)

Excludes

• supervision related to clinical processes (e.g., inadequate supervision during learning process or according to facility policy) (select “Clinical supervision”)

Includes

• inaction around staff accountability;

  lack of knowledge of staff competencies, follow-through;

  inadequate skills in motivation, change, supervision

Excludes

Includes

Excludes

• individual staff member’s feelings of stress due to normal pharmacy operation (select “Human or environmental factors: Pharmacist or staff Stress”); inadequate staffing levels (select “Staffing levels”)

Includes

• close to closing time,

• management time-to-completion policies,

• pressure created by pharmacy wait times or prescription backlog (also select “Pharmacy wait times or prescription backlog”)

Excludes

Includes

• lack of staff understanding, technical skill, clinical knowledge; staff familiar with policy or procedure, but performed procedure incorrectly

Excludes

• competency training (select “Job orientation or training”); delegation of task or care to inadequately prepared staff (select “Assignment or work allocation”); inappropriate staff assignment (select “Assignment or work allocation”)

  A, H, N only: staff assigned to the wrong unit or patient (select “Assignment or work allocation”)

Includes

• inadequate or disproportionate staffing levels; chronic or acute staffing problems; inadequate or insufficient numbers and/or types of staff for patient care needs

Excludes

• inappropriate staff assignment (select “Assignment or work allocation”)

Includes

• frequent changes in facility or unit staff

Excludes

• one-time change in staff assignment or work allocation (select “Assignment or work allocation”)

Includes

• inadequate supervision during learning process

  N only: inadequate supervision of social services staff, activities staff, dietary staff, office staff, clinical staff, etc.

Excludes

• inadequate staff competencies (select “Staff competencies”); tasks performed by untrained or inadequately trained staff (select “Job orientation or training”)

Includes

• facility does not have an internal incident reporting system;

  internal reports are not analyzed to identify areas of risk;

  no system in place to identify areas of risk that have not already resulted in an adverse event or harm to a patient

Excludes

• staff were unaware of how to make an internal report, or what should be reported (select “Internal reporting”)

Includes

• agency or independent staff filling a short-term position or a vacant shift

Excludes

• temporarily assigned internal facility staff (e.g., relief, float, resource, travelers); delegation of task or care to inadequately prepared staff; inappropriate staff assignment (select “Assignment or work allocation”);

  A, H, N only: staff assigned to the wrong unit or patient (select “Assignment or work allocation”); inadequate staffing levels, chronic or acute staffing problems, inadequate or insufficient numbers and/or types of staff for patient care needs (select “Staffing levels”);

  new staff was not adequately trained or oriented (select “Job orientation or training”)

  N only: frequent changes in facility or unit staff (select “Staffing turnover”)

  P only: inadequate or disproportionate staffing levels (select “Staffing levels”)

Includes

Excludes

Includes

• P only: bundling error

Excludes