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

*Corresponding author for this work

Research output: Contribution to journalArticle


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.

Original languageEnglish
Article number102920
Number of pages8
JournalApplied Ergonomics
Early online date19 Aug 2019
Publication statusPublished - 1 Jan 2020



  • Error
  • Patient safety
  • Taxonomy

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