Theme | Subtheme | Definition | Frequency |
---|---|---|---|
1) Latent errora | 1.1 Multiple oxygen therapy policies | • Presence of multiple oxygen therapy polices | 12 |
2) Active failuresa | 2.1 Coordinationb | • Error during discussion with the patient • Incomplete/incorrect readback/feedback | 2 4 |
2.2 Verificationb | • Error related to the identification of the patient • Failure to verify the infection control status | 3 1 | |
2.3 Monitoringb 2.4 Interventionb | • Partially completes a respiratory assessment • Failure to recognise abnormal assessment findings • Administers incorrect/ineffective physiotherapy intervention • Error in physiotherapy skill administration • Failure to obtain oxygen prescription prior to administration • Infection control violation • Moving and handling violation | 11 5 7 1 9 3 7 | |
3) Error-producing factorsa | 3.1 Environmental 3.2 Individual | • Lack of environmental provisions • Lack of knowledge • Lack of physiotherapy skills | 12 10 20 |
4) Defencesa | 4.1 Identifies the patient 4.2 Effective communication with the patient 4.3 Effective communication/complete readback 4.4 Recognises abnormal assessment findings 4.5 Seeks/obtains oxygen therapy prescription 4.6 Correctly implements oxygen therapy 4.7 Appropriate chest physiotherapy intervention 4.8 Adheres to infection control procedures 4.9 Adheres to moving and handling procedures 4.10 Structured handover 4.11 Unstructured handover | • Correct identification of the patient • Demonstrates effective communication with the patient • Demonstrates effective communication/complete readback/feedback • Demonstrates the ability to recognises abnormal assessment findings • Seeks/obtains oxygen therapy prescription from doctor prior to administration • Correctly implements and increase in oxygen therapy • Selects and delivers appropriate chest physiotherapy intervention • Demonstrates adherence to infection control procedures • Demonstrates adherence to moving and handling procedures • Structured handover using SBAR tool • Handover (unstructured) Total | 2 8 4 8 3 12 7 11 5 1 10 107 |
Errors corrected by participants following reassessment of the patient (reflecting-in-action during the scenario) | 2 | ||
Errors uncorrected by participants (during the scenario) | 105 | ||
Errors identified during reflexive interview (reflecting-on-action during the video-reflexive interview) | 26 | ||
Total errors identified (during the scenario and interview) | 28 | ||
Total unidentified errors (during the scenario and interview) | 79 |