Based on Reason’s work, Vincent 1 developed an organisational accident model which helps to visualize the multiplicity of factors that can be associated to an incident:
Organizational accident model. From Vincent C. Patient Safety. 2nd ed. Singapore: Wiley-Blackwell BMJ Books; 2010.
Considering Vincent’s model, we see that healthcare workers are at the sharp end of the clinical environment, which means that when a major incident occurs one must have a wider approach to understand what has happened. Despite the actions of the individuals could play an important role, their behaviour is influenced by the conditions of their work environment and by broader organisational processes.
At some point of its professional life, a healthcare worker will be involved in an error, which can be a highly stressful experience even when it causes no harm, or it doesn’t reach the patients (near misses). 2
Instead of looking just for the individual directly involved, one must appraise the broader system and what had led to the mistake/lapse/etc. The factors that influence the clinical practice and that can be considered as error producing conditions 3 can be summarized as follows:
Framework of contributory factors influencing clinical practice:
|Factor types||Contributory influencing factor|
|Patient factors||Condition (complexity and seriousness)|
Language and communication
Personality and social factors
|Task and technology factors||Task design and clarity of structure|
Availability and use of protocols
Availability and accuracy of test results
|Individual (staff) factors||Knowledge and skills|
Physical and mental health
|Team factors||Verbal communication|
Supervision and seeking help
|Work environmental factors||Staffing levels and skills mix|
Workload and shift patterns
Design, availability, and maintenance of
Administrative and managerial support
|Organisational and management|
|Financial resources and constraints|
Policy, standards, and goals
Safety culture and priorities
|Institutional context factors||Economic and regulatory context|
National health service executive
Links with external organisations
- Vincent C. Patient Safety. 2nd ed. Singapore: Wiley-Blackwell BMJ Books; 2010.
- Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, et al. The emotional impact
of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient
- Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical
medicine. Br Med J. 1998;316(7138):1154–7.