Using medicolegal data to support safe medical care: a contributing factor coding framework.
Approach to Improving Safety
Setting of Care
Human factors and patient safety contexts are important to consider when investigating root causes of medical care failure. This commentary describes a framework that applies elements of system safety, teamwork, and organizational culture to medicolegal data analysis. The approach enhanced identification of process weakness to inform safety improvement work. An Annual Perspective discussed the need to revisit processes for root cause analysis.