TABLE 4.

Factors That Contributed to Events Reported in Phase 2

FactorNo. of Events With Factor Reported% of All Events (n = 584) in Which Factor Was Reported
Practices
 Failure to follow policy or protocol27346.8
 Communications problem13122.4
 Error in charting or documentation7813.4
 Labeling error569.6
 Poor teamwork508.6
 Calculation error406.9
 Error in computer entry376.3
 Nursing handoff or shift change335.7
 Inadequate protocol264.5
 Lack of supervision193.3
 Physician handoff or shift change122.1
 Wrong protocol used91.5
 Inability to contact needed staff61.0
 Inadequate security20.3
Human factors
 Inattention15726.9
 Distraction6911.8
 Inexperience5910.1
 Inadequate training356.0
 Fatigue335.7
 Stress264.5
 Confrontational or intimidating behavior40.7
Staffing
 High patient acuity in unit406.9
 High census in unit233.9
 Low levels of other professional staff172.9
 Low nursing staff levels132.2
 Consultant or subspecialist unavailable71.2
 Low physician staff levels50.9
 Low levels of clerical or support staff20.3
Equipment
 Poor equipment design295.0
 Equipment failure203.4
 Inadequate equipment maintenance142.4
 Unfamiliar equipment111.9
 Necessary equipment unavailable61.0
Environment
 Lack of space or room71.2
 Unfamiliar environment50.9
 Noise10.2
 Inadequate lighting10.2