Directed Blame and Contributory Factors in Safety Incident Reports
| Contributory Factor | Reports No. | Directed Blame No. (%) | OR (95% CI)a |
|---|---|---|---|
| Staff factors (eg, staff knowledge, failure to follow protocols) | 351 | 203 (58) | 1.7 (1.3–2.3) |
| Organizational factors (eg, staffing level, continuity of care) | 216 | 122 (56) | 1.4 (1.0–1.9) |
| Patient factors (eg, frailty, language barrier) | 263 | 100 (38) | 0.5 (0.4–0.7) |
| Equipment factors (eg, faulty or missing equipment) | 35 | 8 (29) | 0.3 (0.1–0.6) |
| No contributory factors reported | 1,283 | 461 (36) | … |
| All reports | 2,148 | 894 (42) | … |
OR=odds ratio.
↵a Comparing odds of directed blame where contributory factor is present vs odds of blame where an alternative contributory factor is present.