Table 3

Description of categories of the Eindhoven Classification Model: PRISMA medical version

Main category	Subcategory	Code	Description	Examples (if available)	Discharged home frequencies n (%)*	Admitted frequencies n (%)*
Technical	External	T-ex	Technical failures beyond the control of the organisation.	Not available.	0 (0)	0 (0)
	Design	TD	Failures due to poor design of equipment, etc.	Not available.	0 (0)	0 (0)
	Construction	TC	Correct design inappropriately constructed or placed.	Not available.	0 (0)	0 (0)
	Materials	TM	Material defects not classified under TD or TC.	Not available.	0 (0)	0 (0)
Organisational	External	O-ex	Failures at an organisational level beyond the control and responsibility of the investigating team.	Patient presented to the ED due to delay in time to operate due to delay in receiving patient information from an external hospital.	0 (0)	1 (1.4)
	Transfer of knowledge	OK	Failure resulting from inadequate measures to train or supervise new or inexperienced staff.	Not available.	0 (0)	0 (0)
	Protocols	OP	Failures relating to the quality or availability of appropriate protocols.	Oncological patient who is instructed by the specialist to present to the ED when he has fever.	1 (1.2%)	2 (2.7)
	Management priorities	OM	Internal management decisions which reduce focus on patient safety when faced with conflicting priorities.	Patient presented to the ED because there is no short-term outpatient department appointment available. Presentation due to long waiting time until operation.	7 (8.2)	5 (6.7)
	Culture	OC	Failure due to attitude and approach of the treating organisation.	Patient is sent from the outpatient department to the ED by a specialist instead of to the GP.	1 (1.2)	1 (1.4)
Human	External	H-ex	Human failures beyond the control of the organisation/department.	Patient arrived at the ED with an ambulance, which was called by bystanders after a fall on the street.	1 (1.2)	0 (0)
	Knowledge-based behaviour	HKK	Failure of an individual to apply their knowledge to a new clinical situation.	GP thought the fever was due to influenza instead of rheumatism. Therefore inadequate treatment and presentation to ED.	1 (1.2)	2 (2.7)
	Qualifications	HRQ	An inappropriately trained individual performing the clinical task.	Not available.	0 (0)	0 (0)
	Coordination	HRC	A lack of task coordination within the healthcare team.	Not available.	0 (0)	0 (0)
	Verification	HRV	Failure to correctly check and assess the situation before performing interventions	GP refers the patient to the ED directly without examining the patient adequately due to lack of time.	3 (1.9)	0 (0)
	Intervention	HRI	Failure resulting from faulty task planning or performance.	Inadequate medication schedule, therefore progression of complaints. Inadequate explanation to the patient when to present to the ED.	4 (4.7)	3 (4.0)
	Monitoring	HRM	Failure to monitor the patient’s progress or condition.	Patient was admitted to the hospital, no adequate analysis of complaints and discharged home. Presents to the ED with same complaints. Insufficient monitoring done by GP.	1 (1.2)	1 (1.4)
	Skills-based	HSS	Failure in performance of highly developed skills.	Not available.	0 (0)	0 (0)
Patient	Patient-related	PRF	Failures related to patient characteristics or conditions, which are beyond the control of staff and influence clinical progress.	Patient falls due to refusal to walk with walking aid. Patient postponed GP appointment due to anxiety and presents to ED with heavy complaints.	18 (21.2)	10 (13.5)
Patient	Disease-related	DRF	Failures related to the natural progress of disease which are beyond the control of the patient, its carers and staff.	Patient with COPD presents with acute progression of dyspnoea. Shoulder luxation after fall.	46 (54.1)	47 (63.5)
X	Unclassifiable	X		Trauma capitis due to fall of suitcase during flight. Patient is still living independently despite frailty. Uncertainty of GP resulting in referral to ED. Patient presents to ED with postoperative infection.	2 (2.3)	2 (2.7)
Total					85 (100)	74 (100)

Distribution of 159 root causes based on 100 patient cases.
*Number of root causes.
COPD, chronic obstructive pulmonary disease; ED, emergency department; GP, general practitioner; PRISMA, Prevention and Recovery Information System for Monitoring and Analysis.