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Table 6 Video analysis of error types and defences

From: Using video-reflexive ethnography and simulation-based education to explore patient management and error recognition by pre-registration physiotherapists

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
  1. MRSA methicillin-resistant staphylococcus aureus, SBAR Situation, Background, Assessment and Recommendation [62]
  2. aA priori error typology themes from Reason [76]
  3. bActive failure a priori subthemes from Henneman et al. [63]