Table 3 Definitions of the Eindhoven classification model with examples
Definitions of the Eindhoven classification model with examples | ||||
|---|---|---|---|---|
Main category | Subcategory | Code | Definition | Example |
Technical | External | T-ex | Technical failures beyond the control of the organization. | -Vacuum wound pump was not working |
| Â | Design | TD | Failures to poor design of equipment etc. | Â |
| Â | Construction | TC | Correct design inappropriately constructed or placed. | Â |
| Â | Materials | TM | Material defects not classified under TD or TC. | -Stiches broke from the abdominal drain |
Organizational | External | O-ex | Failures at an organizational level beyond the control and responsibility of the investigating team. | Â |
| Â | Transfer of knowledge | OK | Failure resulting from inadequate measures to train or supervise new or inexperienced staff. | Â |
| Â | Protocols | OP | Failures relating to the quality or availability of appropriate protocols. | -Not following pain treatment protocol after surgery |
| Â | Management priorities | OM | Internal management decisions which reduce focus on patient safety when faced with conflicting priorities. | -No bed available at ICU |
| Â | Culture | OC | Failure due to attitude and approach of the treating organization. | Â |
Human | External | H-ex | Human failures beyond the control of the organization/department | -Impassable jejunal feeding tube as a consequence of inadequate flushing by the homecare nurse |
| Â | Knowledge based behavior | HKK | Failure of an individual to apply their knowledge to a new clinical situation | -Physician gave another order to supply fluid despite non-responsiveness of the patient in urine production and tension. |
| Â | Qualifications | HRQ | An inappropriately trained individual performing the clinical task | Â |
| Â | Coordination | HRC | A lack of task co-ordination within the healthcare team | Â |
| Â | Verification | HRV | Failure to correctly check and assess the situation before performing interventions | Â |
| Â | Intervention | HRI | Failure resulting from faulty task planning or performance | -No prescribed anticoagulation by the ward doctor like advised by anaesthesiologist |
|  | Monitoring | HRM | Failure to monitor the patient’s progress or condition |  |
| Â | Skills-based | HSS | Failure in performance of highly developed skills | -Luxation wound catheter |
Patient | Patient-related | PRF | Failures related to patient characteristics or conditions, which are beyond the control of staff and influence clinical progress | -Patient did not take prescribed medication |
| Â | Disease-related | DRF | Failures related to the natural progress of disease which are beyond control of patient, its carers and staff | -Inflammation of the skin near the insertion of the abdominal drain, -Biliary pancreatitis |
X | Unclassifiable | X | X | -Origin of blood loss objectivated by the patient was not found |
| Â | Â | X-nrc | This root cause has no relation with the initial surgery nor rehabilitation after the initial surgery | -ER visit due to appendicitis or galstones |
| Â | Â | X-FIP | Failures related to the healthcare delivered by the family caregiver | -Detoriation or infection of wounds as a consequence of inadequate healthcare provided by the family caregiver. |