Improvement Academy: Yorkshire Contributory Factors Framework

Summary

Patient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring. 

The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. 

The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents. 

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