Examining Patient Safety Events Using the Behaviour Change Wheel: A Cross-Sectional Analysis.

Area of Science:

• Healthcare Quality Improvement
• Patient Safety Research
• Behavioral Science in Medicine

Background:

• Precursor-level safety events (PSEs) represent significant patient risk, yet their underlying causes remain poorly understood.
• Identifying determinants of PSEs is crucial for developing effective patient safety interventions.
• Existing research lacks a comprehensive understanding of the factors driving PSEs.

Purpose of the Study:

• To apply the Behaviour Change Wheel (BCW) framework to understand the determinants of PSEs.
• To assess the alignment between identified PSE determinants and proposed intervention action items.
• To evaluate the effectiveness of current intervention strategies for PSEs.

Main Methods:

• A cross-sectional study analyzed 58 prerecorded PSEs in a maternal/pediatric hospital.
• The Behaviour Change Wheel (BCW) was used to independently code determinants and action items for each PSE.
• A matrix analyzed the alignment between behavioral determinants and intervention types.

Main Results:

• Six behavioral determinants and seven intervention types were identified across 58 PSEs.
• Environmental context/resources (25.4%) was the most frequent determinant; education (45.8%) was the most common intervention.
• Only 34.2% of determinants aligned with interventions, while 37.8% did not, and 28.1% lacked sufficient information for coding.

Conclusions:

• A significant disconnect exists between the determinants of PSEs and the interventions implemented, with over a third showing poor alignment.
• Educational interventions, often ineffective for the identified behaviors, were disproportionately used.
• Limited information in PSE reporting hinders accurate assessment, highlighting the need for systematic, behavior-informed approaches to patient safety.