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Table 4 Distribution of triggered contributory factors among the cohort

From: Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

ALARM categories

Distribution of triggered contributory factors

Category description

Subcategory description

Factors

Per question N (%)

Per category %

I. PATIENT

FACTORS

1.1 Medical history

Q1

1 (6.6%)

24.4% (33/135)

1.2 Health status

Q2

4 (26.6%)

Q3

8 (53.3%)a

Q4

15 (100%)a

1.3 Medications

Q5

2 (13.3%)

1.4 Personality, social and familial factors

Q6

2 (13.3%)

Q7

0 (0%)

1.5 Conflictual relationships

Q8

1 (6.6%)

Q9

0 (0%)

II. TASK

FACTORS

2.1 Protocols availability and use

Q10

14 (93.3%)a

31.6% (38/120)

2.2 Test results availability and accuracy

Q11

4 (26.6%)

Q12

5 (33.3%)

Q13

4 (26.6%)

2.3 Tasks design and clarity

Q14

1 (6.6%)

2.4 Planning and scheduling

Q15

2 (13.3%)

Q16

0 (0%)

Q17

8 (53.3%)a

III. INDIVIDUAL (STAFF) FACTORS

3.1 Competence, technical and non-technical skills

Q18

0 (0%)

21.7% (13/60)

Q19

1 (6.6%)

Q20

7 (46.6%)

3.2 Physical and mental health

Q21

5 (33.3%)

IV. TEAM FACTORS

4.1 Communication with staff

Q22

7 (46.6%)

25.2% (34/135)

Q23

3 (20%)

4.2 Communication with patient and family

Q24

2 (13.3%)

4.3 Patient record

Q25

9 (60%)a

Q26

10 (66.6%)a

4.4 Crucial information sharing

Q27

1 (6.6%)

4.5 Supervision

Q28

1 (6.6%)

4.6 Support

Q29

0 (0%)

Q30

1 (6.6%)

V. WORK ENVIRONMENT FACTORS

5.1 Physical environment maintenance and hygiene

Q31

0 (0%)

11.7% (21/180)

5.2 Patient transfer

Q32

0 (0%)

5.3 Supplies and equipment design, availability and maintenance

Q33

2 (13.3%)

Q34

0 (0%)

Q35

0 (0%)

5.4 Computized Information system

Q36

4 (26.6%)

5.5 Staffing levels and skills mix

Q37

0 (0%)

Q38

1 (6.6%)

5.6 Workload

Q39

4 (26.6%)

Q40

1 (6.6%)

5.7 Procedures timing

Q41

1 (6.6%)

Q42

8 (53.3%)a

VI. MANAGEMENT AND INSTITUTIONAL CONTEXT FACTORS

6.1 Organizational structure

Q43

0 (0%)

16.6% 20/120

6.2 Human resources

Q44

2 (13.3%)

6.3 Policy, standards and goals

Q45

0 (0%)

6.4 Subcontracting management

Q46

0 (0%)

6.5 Purchasing policy

Q47

1 (6.6%)

6.6 Adverse event declaration and prevention

Q48

14 (93.3%)a

6.7 Financial resources

Q49

0 (0%)

6.8. Wider health service environment

Q50

3 (20%)

  1. aFactors incriminated in more than half of the cases