Table 10 Causes of perioperative ‘near-misses’ and adverse events
A: Reported causes (n = 4,346) of the perioperative incidents (n = 2,563) | ||
|---|---|---|
HIMS predefined causes | N | % |
Human | ||
SOP not followed | 702 | 16.2% |
Mistake/forgotten | 669 | 15.4% |
Communication problem | 498 | 11.5% |
Other human acting, namely*) | 449 | 10.3% |
SOP not known | 245 | 5.6% |
Professional not capable for task | 161 | 3.7% |
Distracted | 105 | 2.4% |
Unqualified or incorrect performance | 77 | 1.8% |
Incorrect use | 40 | 0.9% |
Wrong record filing | 20 | 0.5% |
Total human | 2,966 | 68.2% |
Organizational | ||
Other organizational, namely*) | 315 | 7.2% |
SOP not available, incomplete, or unclear | 217 | 5.0% |
Culture at workplace | 114 | 2.6% |
High workload | 115 | 2.6% |
Equipment/supply related, namely*) | 67 | 1.5% |
Inadequately trained professional | 67 | 1.5% |
Medical devices not available | 62 | 1.4% |
SOP not accessible | 30 | 0.7% |
Unclear instructions | 17 | 0.4% |
Total organizational | 1,004 | 23.1% |
Technical | ||
Broken material | 61 | 1.4% |
Wrong design | 28 | 0.6% |
Total technical | 89 | 2.0% |
Patient-related | ||
Other patient related, namely*) | 91 | 2.1% |
Patient condition | 19 | 0.4% |
Patient behaviour | 18 | 0.4% |
Total patient-related | 128 | 2.9% |
Other, namely *) | 159 | 3.7% |
Total | 4,346 | 100% |
B: Summary of SOP releated causes | ||
SOP not followed | 702 | 16.2% |
SOP not known | 245 | 5.6% |
SOP not available, incomplete, or unclear | 217 | 5.0% |
SOP not accessible | 30 | 0.7% |
Total of SOP related causes | 1,194 | 27,5% |