Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths

Rebecca Mitchell, Mona Faris, Reidar Lystad, Diana Fajardo Pulido, Grace Norton, Melissa Baysari, Robyn Clay-Williams, Peter Hibbert, Andrew Carson-Stevens, Cliff Hughes

Research output: Contribution to journalArticleResearchpeer-review

Abstract

This study aimed to operationalise and use the World Health Organisation's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). Over two-thirds (69.0%) of incidents occurred during treatment and 27.4% occurred in the operating theatre. Clinical process and procedures (55.9%), medication/IV fluids (11.2%) and healthcare-associated infection/complications (10.4%) were the most common incident types. Coroners made recommendations in 44.0% of deaths and organisations undertook preventive actions in 40.0% of deaths. This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths. Further testing of the mICPS is warranted.

LanguageEnglish
Article number102920
Number of pages8
JournalApplied Ergonomics
Volume82
Early online date19 Aug 2019
DOIs
Publication statusPublished - 1 Jan 2020

Fingerprint

Patient Safety
WHO
incident
death
Theaters
Taxonomies
Human engineering
Health care
Coroners and Medical Examiners
Health
Cross Infection
Fluids
taxonomy
medical care
theater
Testing
medication
Organizations
Therapeutics

Keywords

  • Error
  • Patient safety
  • Taxonomy

Cite this

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title = "Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths",
abstract = "This study aimed to operationalise and use the World Health Organisation's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). Over two-thirds (69.0{\%}) of incidents occurred during treatment and 27.4{\%} occurred in the operating theatre. Clinical process and procedures (55.9{\%}), medication/IV fluids (11.2{\%}) and healthcare-associated infection/complications (10.4{\%}) were the most common incident types. Coroners made recommendations in 44.0{\%} of deaths and organisations undertook preventive actions in 40.0{\%} of deaths. This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths. Further testing of the mICPS is warranted.",
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Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths. / Mitchell, Rebecca; Faris, Mona; Lystad, Reidar; Fajardo Pulido, Diana; Norton, Grace; Baysari, Melissa; Clay-Williams, Robyn; Hibbert, Peter; Carson-Stevens, Andrew; Hughes, Cliff.

In: Applied Ergonomics, Vol. 82, 102920, 01.01.2020.

Research output: Contribution to journalArticleResearchpeer-review

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