Patient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimize learning and take action to prevent further incidents occurring. Good practice in incidents investigation has been described by the NPSA in the London Protocol. A key step in this protocol is the identification of all contributory factors. The Clinical Human Factors Group also recommends effective contributory factor analysis as part of serious incident investigation.

In 2012, we conducted a systematic review of 83 research studies focusing on the causes of hospital patient safety incidents. The result of this piece of work is the first evidence-based framework of accident causation in hospitals: the Yorkshire Contributory Factors Framework.

The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimizing 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. Download the supporting research here.

For further information about the YCFF and associated tools please click here.