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

doi:10.1016/j.apergo.2019.102920

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

Appl Ergon. 2020 Jan:82:102920. doi: 10.1016/j.apergo.2019.102920. Epub 2019 Aug 19.

Affiliations

¹ Australian Institute of Health Innovation, Macquarie University, Sydney, Australia. Electronic address: r.mitchell@mq.edu.au.
² Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
³ Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
⁴ Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK.

PMID: 31437756
DOI: 10.1016/j.apergo.2019.102920

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.

Keywords: Error; Patient safety; Taxonomy.

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Child
Child, Preschool
Female
Humans
Infant
Male
Medical Errors / classification*
Middle Aged
Patient Harm / classification*
Patient Harm / mortality*
Patient Safety / statistics & numerical data*
Retrospective Studies
Risk Management / statistics & numerical data*
World Health Organization
Young Adult