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 |