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Reason's accident causation model: application to adverse events in acute care
Malcolm Elliott1, Karen Page, Linda Worrall-Carter
1St Vincent's Centre for Nursing Research, Australian Catholic University, Melbourne, VIC, Australia.
Abstract:
Adverse events are unintended harm to a patient caused by the health care provided; more than half of all these events have been deemed avoidable. Adverse events are a common problem in acute care and represent a breach in care quality and safety. They are generally not caused by a single mistake or error and although safety barriers exist in health care, patients today are still harmed. Using an accident causation model is a constructive way of identifying the underlying causes of adverse events and to strengthen a study's theoretical underpinnings. Reason's model is recommended as a useful framework for adverse event analysis as it promotes a focus on the conditions or situation in which the clinician was trying to perform, rather than apportioning blame.
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