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Initial Build

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SE 9/2/2021

Staff Review

Status
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titleDone
Suzanne Wood

Approval Status

Status
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titleapproved
7/27/2022

Description

Determination of which contributing factor(s) related to the organization are known.

On-Screen Instructions

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Check all that apply excerpt

Field Type

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Checkbox excerpt

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Top
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Responses

Table of Contents
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excludeDescription|On-Screen Instructions|Field Type|Responses|Response Codes|OPSC Staff Notes|History|Guide for Use|Additional Support

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budget
budget
Adequacy of budget

An inadequate budget contributed to the event.

Includes

  • Unit budget

  • Facility budget

Excludes

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No additional guidance excerpt

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workAssignment
workAssignment
Assignment or work allocation

Conditions related to staff assignment or work allocation contributed to the event.

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”)

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clinicalSupervision
clinicalSupervision
Clinical supervision

Ineffective supervision during or related to clinical processes contributed to the event.

Includes

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

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

Excludes

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

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

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

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cultureOfSafety
cultureOfSafety
Culture of safety

The facility’s culture of safety (or lack thereof) contributed to the event.

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 adverse events 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 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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No additional guidance excerpt

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internalReporting
internalReporting
Internal reporting

Facility’s internal system for reporting adverse events or unsafe conditions contributed to the event.

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)

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training
training
Job orientation or training

The inadequacy of the facility’s job orientation or training contributed to the event.

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)

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managerialSupervision
managerialSupervision
Managerial supervision

Ineffective supervision during or related to non-clinical processes contributed to the event.

Includes

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

Excludes

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

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managementSkills
managementSkills
Management or leadership skills

Ineffective or inadequate management or leadership skills contributed to the event.

Includes

  • inaction Inaction around staff accountability;

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

  • inadequate Inadequate skills in motivation, change, supervision

Excludes

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AnchorwaitTimeswaitTimesPharmacy wait times or prescription backlog

Pharmacy’s system for processing prescriptions or providing customer service is overcapacity and contributed to the event.

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”)

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AnchorproductionPressuresproductionPressuresProduction pressures

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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No additional guidance excerpt

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competencies
competencies
Staff competencies

Inadequate staff competencies contributed to the event.

Includes

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

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

Excludes

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staffing
staffing
Staffing levels

Staffing levels contributed to the event.

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”)

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AnchorturnoverturnoverStaffing turnover

Gaining or losing employees contributed to the event

Includes

  • frequent changes in facility or unit staff

Excludes

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supervisionsupervisionSupervision

Ineffective supervision contributed to the event.

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”)

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systemsToIDRisk
systemsToIDRisk
Systems to identify risk

Inadequate systems to identify risk in the facility contributed to the event.

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)

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tempStaffing
tempStaffing
Temporary staffing

Conditions related to the use of temporary staff contributed to the event.

Includes

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

Excludes

[Definition goes here.]

Includes

Excludes

  • temporarily Temporarily assigned internal facility staff (e.g., relief, float, resource, travelers) ; delegation (select “Assignment or work allocation”)

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

  • Inappropriate staff assignment (select “Assignment Assignment or work allocation”allocation); A, H, N only: staff

  • Staff assigned to the wrong unit or patient (select “Assignment Assignment or work allocation”); inadequate 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 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”)

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AnchortempOrNewStaffingtempOrNewStaffingTemporary or new staff

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Other (please describe)

Any other factor related to organizational factors, not included in the list above, which contributed to the event.

Includes

Excludes

  • P only: bundling error

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Guide for Use

Use the following definitions to guide your responses under “Organizational Factors.”

“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)

“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
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Other selection text excerpt
Other selection text excerpt

History

Start Date

2006

End Date

n/a

Change History

Spring 2012: PSRP implementation

Field Name

cf_org_f