Table 5 Tagging framework HTOPS 2018
Tag 1: Human influences (including physical and emotional behaviour) | |
|---|---|
 Action | Something you do not do or should not be doing and as such is an inappropriate action e.g. a procedure like handwashing. Propping a door open when it should be shut, needle stick injury, not putting sharps in the bin properly |
 Complacency | FYI read patient S number from memory, taking short cuts, e.g. being in a rush to go to the next patient in a ward round |
 Communication | Practitioners: Cannot read handwriting, wiping the theatre board of patient data before theatre finished, poor communication between doctor and nurse, poor introduction(s), poor incomplete handover and manipulative communication Patients: Checking for ID/confirm who you are, incorrect name above the bed |
 Confidentiality | Leaving computers open and unattended, leaving notes unattended. Talking about patients in public spaces with colleagues, or in-front of patients |
 Dignity | Leaving curtains open, patient exposed, patient hurt or caused some type of distress, patient pulled backwards in a wheel chair, patient referred to by room number condition, as ‘him’ or ‘her’ |
 Distraction | Something or someone who is distracting another, interruptions |
 Doing the Job | Prescribing, consenting, ordering, swab count, unlabelled specimen container, not writing clearly in the notes, using not up to date results, failure to ask about pain |
 Hygiene | Infection control and risk—e.g. hand washing |
 Language | Practitioner e.g. foreign, using jargon, abbreviations Patient e.g. foreign, deafness, disability dementia, disregard to cultural needs |
 Leadership | Self-awareness, awareness of others, ability to praise or admonish another. Leadership in collaborative patient-centred teams. Poor involvement of the patient in the team |
 Privacy | Overhearing private conversations, patient in ward hears what is being discussed at the ward desk |
 Professional | Decision making e.g. failure to use correct medication (lack of knowledge, missed allergy, wrong dose), medical interference e.g. unnecessary procedure test completed, not stopping a medication during surgical pathway; being unkind to a colleagues with loss of self-control; not acknowledging and listening to patient worries; and lack of patient centredness. Civility, respect and responsibility for personal health. |
 Situation awareness | Definition = ‘Our mental picture of what is happening around us and what is about to happen’ (Mitchell, pg. 27). See issues about an individual or about the environment around you or the systems you are using. Wrong site for surgery. Staff complaining about their work life to patients. Counting swabs in memory not aloud |
 Skills | Insufficient experience |
 Stress and fatigue | Exhausted staff who are complaining they are not having breaks and short cuts taken. Staff, volatile emotions and poor moral |
 Team functioning | Clearly not relating to everyone in a team. Team fails to connect with one another; missing member of the team. |
Tag 2: Work environment | |
 Equipment | No BP machine. Appropriate specialist equipment not available or working. Wet plaster left on floor, phone issues, missing items in a theatre-pack |
 Hardware | Furniture, physical component of a building and how it is cared for air conditioning, cleanliness, door propped open, wet floor, endoscope issues |
 Layout/design | Seating, inadequate meeting space, wrong bed type, no wheel chair space |
 Software | IT—computers and software used to support clinical activities, slow computer responses, not enough, no Wi-Fi on the ward, mouse not working, electronic prescribing issues, not logging off computer and ICE not working |
Tag 3: Systems | |
 Checking lists | Patient ID, WHO check list and check lists |
 Equipment | Repairs and maintenance. How failures or broken things are fixed, charging of electronic equipment |
 Hand overs | Lost drug keys |
 Insufficient staff skill mix | Too few staff or too many and inappropriate level of staff. Insufficient staff, no breaks as not enough staff, and insufficient skill mix. Change over doctor, induction and support for any staff. |
 Management/leadership | Ordering materials for a ward/unit. Staff rota, clinic set up, are asset up. Access for personal log in. Ordering materials and equipment. Who types us notes and who knows. Case selection for the right clinician. |
 Records | Documentation/forms. How notes are accessed or made available; Appointments and how they are made; multiple copies of patient notes |
 Transport | Ambulance and taxi issues |