Table 3

​Types and frequencies of contributory factors with illustrative quotes

Contributory factorsNIllustrative quotes from incidents
Family carer factors: These are features of the family carer or their circumstances that make caring for the child more difficult, or may contribute to problems in care.4 Safeguarding concerns:
Report received from the mother of a child who receives continuing care support that the child has been sleeping on an inappropriate piece of equipment. The child is at high risk of developing pressure sores and has been sleeping on a blow-up lilo. He is completely immobile and tracheostomy- and oxygen-dependent (…)There are ongoing child protection concerns which necessitate the requirement for dad’s continued input into the child’s care.”
“A long-term ventilated child via a tracheostomy was taken to school without his emergency tracheostomy bag. Sometimes it is a rush to get out in the morning and this may have been a contributing factor.”
Equipment factors: These are factors relating to the design of equipment which affect the provision of care.12 Factors relating to manufacturing or suppliers
Issues with packaging: “Prior to changing trachy tube I noted that the tube I was planning to insert was a different length to the tube I was replacing. The other tube was correct length. The details are very similar on both boxes, which look very similar.”
Crucial information missing from equipment instructions: “Equipment supplied from manufacturers did not have the cleaning instructions in place, if the filters became wet the device would not work.”
Organisational factors: These are features of the way organisations function which affect the provision of care available.12 Weekends and out-of-hours: “Phone call received from LTV (long-term ventilation) patient whose humidifier had failed out-of-hours. As per protocol the parent had called the local hospital where a spare was kept but they were unable to find it.”
Staffing pressures: “A 24 hours ventilator-dependent tracheostomy child was discharged home following a very prolonged hospital admission. Child under care of children’s long-term ventilation team. Standard of care is that every trache (tracheostomy) long-term vent (ventilation) patient is visited within 24 hours of discharge to follow-up patient and ensure no issues have arisen and troubleshoot any problems. Due to nurse vacancy within the service and only part-time physio within the service the service was unable to offer a home visit until days later.”
Patient factors: Features of a patient that make caring for them more difficult and therefore more prone to error.10 Communication challenges
Complex needs: Community patient who is quadriplegic and is ventilated via tracheostomy was unable to summon help when airway needed clearing while he was at home in bed. He has very limited verbal communication which is worse if airway compromised.”
Child distressed: “Known risk child will de-cannulate when anxious or displaying behaviours. At 15:15 child was tired and upset and pulled her tracheostomy out.”
Staff performance factors: Features of individual staff members that may contribute in some way to problems in care.10 Staff panic while changing tracheostomy: “Child needed to have tracheostomy tapes changed. Staff liaised about who was going to hold the tracheostomy and who was going to change the tapes. Staff member two decided agreed to hold the tube in place while staff member one changed the tapes. While the tapes were being changed, child proceeded to vomit. As staff member one sat child up, staff member two let go of the tracheostomy and staff member one stated that the tracheostomy tube nearly fell out. Staff member one stated that she had shouted at staff member two, with staff member two stating that she had panicked.”
Environmental factors:
Features of the environment that may contribute to problems in care.
2 Child is on a plane: “Child who has long term ventilation was on a flight back from holiday and required ventilation. The portable ventilator failed after 15 min and the child had to be woken up and kept awake so she could breathe unaided.”
Child is in a swimming pool: “Patient attending pool session at school. Became unwell in the water so removed from the pool by school staff with LTV staff on poolside.”