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Description
Determination of which contributing factor(s) related to the organization are known.
On-Screen Instructions
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Field Type
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Conditions related to staff assignment or work allocation contributed to the event.
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 (select “Staffing levels”)
Chronic or acute staffing problems (select “Staffing levels”)
Insufficient numbers and/or types of staff for patient care needs (select “Staffing levels”)
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The facility’s culture of safety (or lack thereof) contributed to the event.
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 pharmacists, 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
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Facility’s internal system for reporting adverse events or unsafe conditions contributed to the event.
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”)
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The inadequacy of the facility’s job orientation or training contributed to the event. “Job orientation/training” is the acquisition of knowledge and skills as a result of teaching of vocational or practical skills and knowledge to enhance the performance of employees
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”)
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Ineffective or inadequate management or leadership skills contributed to the event.
Includes
Inaction around staff accountability
Lack of knowledge of staff competencies, follow-through
Inadequate skills in motivation, change, supervision
Excludes
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Pharmacy’s system for processing prescriptions or providing customer service is overcapacity and contributed to the event.
Includes
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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”)
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Actual and/or perceived requirement to deliver a service (i.e. a prescription) quickly.
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
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Inadequate staff competencies contributed to the event. “Staff competencies” are identified fundamental knowledge, skills, and abilities defined in terms of the behaviors needed for successful job performance (typically specific to both job role and organization).
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”)
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”)
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Ineffective supervision contributed to the event.
Includes
Inadequate supervision during learning process
Excludes
Inadequate staff competencies (select “Staff competencies”)
Tasks performed by untrained or inadequately trained staff (select “Job orientation or training”)
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Inadequate systems to identify risk in the facility contributed to the event.
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”)
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Conditions related to the use of temporary staff contributed to the event.
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) (select “Assignment or work allocation”)
Delegation of task or care to inadequately prepared staff (select “Assignment or work allocation”)
Inappropriate staff assignment (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”)
Inadequate or disproportionate staffing levels (select “Staffing levels”)
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🚨 [Definition goes here.]
Other (please describe)
Any other factor related to organizational factors, not included in the list above, which contributed to the event.
Includes
Bundling error
Excludes
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Guide for Use
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History
Start Date | 2006 |
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End Date | n/a |
Change History | 2013: PSRP implementation |