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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
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