Table 2

Identified themes and subthemes based on the CPSI safety tool kit and their proportions

Theme	Subtheme	Subtheme domains	Frequency	% of total	% within theme
Before the incident			134	35.7
	Training		46		34.3
	Organisational and leadership support		39		29.1
	Just and safe culture		28		20.9
	Availability of resources		21		15.7
Immediate response			170	45.3
	Care for reporter		31		18.2
	Confidentiality		41		24.1
	Reporting the incident		98		57.6
		User friendly	37		37.8*
		External and internal influencers	32		32.7*
		Incident characteristics	29		29.6*
Prepare for analysis			12	3.2
	Preliminary investigation		5		41.7
	Appropriate analysis methods		0
	Identify team		6		50.0
	Interview plan		1		8.3
Analysis process			12	3.2
	Investigate what happened		5		41.7
	Understand why and how happened		1		8.3
	Develop and manage recommendations		6		50.0
Follow through			16	4.3
	Implement		11		68.8
	Follow and assess		5		31.3
Close the loop			31	8.3
Close the loop	Share learn internally and externally		31		100
Total			375

*The percentage of reported factors to total number under the subtheme ‘reporting the incident’.
CPSI, Canadian Patient Safety Institute.