Factors That Contributed to Events Reported in Phase 2
Factor | No. of Events With Factor Reported | % of All Events (n = 584) in Which Factor Was Reported |
---|---|---|
Practices | ||
Failure to follow policy or protocol | 273 | 46.8 |
Communications problem | 131 | 22.4 |
Error in charting or documentation | 78 | 13.4 |
Labeling error | 56 | 9.6 |
Poor teamwork | 50 | 8.6 |
Calculation error | 40 | 6.9 |
Error in computer entry | 37 | 6.3 |
Nursing handoff or shift change | 33 | 5.7 |
Inadequate protocol | 26 | 4.5 |
Lack of supervision | 19 | 3.3 |
Physician handoff or shift change | 12 | 2.1 |
Wrong protocol used | 9 | 1.5 |
Inability to contact needed staff | 6 | 1.0 |
Inadequate security | 2 | 0.3 |
Human factors | ||
Inattention | 157 | 26.9 |
Distraction | 69 | 11.8 |
Inexperience | 59 | 10.1 |
Inadequate training | 35 | 6.0 |
Fatigue | 33 | 5.7 |
Stress | 26 | 4.5 |
Confrontational or intimidating behavior | 4 | 0.7 |
Staffing | ||
High patient acuity in unit | 40 | 6.9 |
High census in unit | 23 | 3.9 |
Low levels of other professional staff | 17 | 2.9 |
Low nursing staff levels | 13 | 2.2 |
Consultant or subspecialist unavailable | 7 | 1.2 |
Low physician staff levels | 5 | 0.9 |
Low levels of clerical or support staff | 2 | 0.3 |
Equipment | ||
Poor equipment design | 29 | 5.0 |
Equipment failure | 20 | 3.4 |
Inadequate equipment maintenance | 14 | 2.4 |
Unfamiliar equipment | 11 | 1.9 |
Necessary equipment unavailable | 6 | 1.0 |
Environment | ||
Lack of space or room | 7 | 1.2 |
Unfamiliar environment | 5 | 0.9 |
Noise | 1 | 0.2 |
Inadequate lighting | 1 | 0.2 |