Includes

• delegation Delegation of task or care to inadequately prepared staff;

• inappropriate Inappropriate staff assignment;

• staff Staff assigned to the wrong unit or patient;

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

Excludes

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

• Inadequate or disproportionate staffing levels, chronic levels (select “Staffing levels”)

• Chronic or acute staffing problems , insufficient (select “Staffing levels”)

• 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”“Staffing levels”)

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

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

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

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

• behavior 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

Includes

• staff were unaware of Staff did not know how to make an internal report, or what should be reported; internal

• Internal reporting is not consistent

Excludes

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

Includes

• routine Routine job training;

• inIn-service education;

• competency Competency training;

• job Job orientation;

• availability Availability of training programs

Excludes

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

Includes

• inaction Inaction around staff accountability;

• lack Lack of knowledge of staff competencies, follow-through;

• inadequate Inadequate skills in motivation, change, supervision

Excludes

Includes

Excludes

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

• Inadequate staffing levels (select “Staffing levels”“Staffing levels”)

Includes

• close Close to closing time,

• management Management time-to-completion policies,

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

Excludes

Includes

• lack Lack of staff understanding, technical skill, clinical knowledge; staff

• Staff familiar with policy or procedure, but performed procedure incorrectly

Excludes

• competency Competency training (select “Job “Job orientation or training”); delegation training”)

• Delegation of task or care to inadequately prepared staff (select “Assignment “Assignment or work allocation”); inappropriate allocation”)

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

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

  allocation”)

Includes

• inadequate Inadequate or disproportionate staffing levels; chronic

• Chronic or acute staffing problems; inadequate

• Inadequate or insufficient numbers and/or types of staff for patient care needs

Excludes

• inappropriate 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”“Assignment or work allocation”)

Includes

• inadequate Inadequate supervision during learning process

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

Excludes

• inadequate Inadequate staff competencies (select “Staff competencies”); tasks “Staff competencies”)

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

Includes

• facility Facility does not have an internal incident reporting system;

• internal Internal reports are not analyzed to identify areas of risk;

• no 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 Staff were unaware of how to make an internal report, or what should be reported (select “Internal reporting”“Internal reporting”)

Includes

• agency 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 Delegation of task or care to inadequately prepared staff ; inappropriate staff assignment (select “Assignment “Assignment or work allocation”allocation”); A, H, N only: staff assigned to the wrong unit or patient (select “Assignment or work allocation”); inadequate

• 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 “Staffing levels”)

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

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

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

Includes

• “Staffing levels”)

Includes

• P only: bundling Bundling error

Excludes