
IDENTIFYING CAUSAL PATTERNS AND ERRORS
IN ADVERSE CLINICAL INCIDENTS
Rebecca Mitchell,Ann Williamson & Brett Molesworth
School of Aviation, University of New South Wales, Australia
This study identified precursor (PE) and associated contributing fac-
tors (CFs) of clinical incidents in health care. A random sample of
498 clinical incidents inAustralia were reviewed. Staff action was the
most common type of PE identified. Correspondence analysis for all
PEs that involved staff action by error type showed that rule-based
errors were strongly related to performing medical or monitoring
tasks and medication issues. Skill-based errors were strongly related ...