|
Error type
|
|
1
|
Wrong dose
|
20 (36.4 %)
|
140 (44.2 %)
|
0.305
|
|
2
|
Wrong drug due to mix-up of drugs
|
9 (16.4 %)
|
51 (16.1 %)
|
1.000
|
|
3
|
Wrong patient due to mix-up of patients
|
14 (25.5 %)
|
34 (10.7 %)
|
0.007
|
|
4
|
Omission
|
3 (5.5 %)
|
35 (11.0 %)
|
0.332
|
|
5
|
Unauthorized drug
|
2 (3.6 %)
|
35 (11.0 %)
|
0.139
|
|
6
|
Wrong route
|
9 (16.4 %)
|
14 (4.4 %)
|
0.003
|
|
7
|
Wrong judgement or inadequate assessment of the patient’s need for treatment
|
1 (1.8 %)
|
9 (2.8 %)
|
1.000
|
|
8
|
Wrong management or storage of the drug
|
1 (1.8 %)
|
7 (2.2 %)
|
1.000
|
|
9
|
Allergy-related error
|
0 (0.0 %)
|
5 (1.6 %)
|
1.000
|
|
Individual contributory factor
|
|
1
|
Negligence, forgetfulness or lack of attentiveness
|
46 (83.6 %)
|
207 (65.3 %)
|
0.007
|
|
2
|
Proper protocol not followed
|
13 (23.6 %)
|
82 (25.9 %)
|
0.867
|
|
3
|
Lack of knowledge
|
17 (30.9 %)
|
37 (11.7 %)
|
0.001
|
|
4
|
Practice beyond scope of practice
|
1 (1.8 %)
|
48 (15.1 %)
|
0.004
|
|
5
|
Inappropiate communication
|
3 (5.5 %)
|
33 (10.4 %)
|
0.328
|
|
6
|
Disease or drug abuse
|
1 (1.8 %)
|
13 (4.1 %)
|
0.703
|
|
System contributory factor
|
|
1
|
Role overload
|
25 (45.5 %)
|
117 (36.9 %)
|
0.233
|
|
2
|
Unclear communication or orders
|
13 (23.6 %)
|
87 (27.4 %)
|
0.624
|
|
3
|
Lack of adequate access to guidelines or unclear organisational routines
|
9 (16.4 %)
|
97 (30.6 %)
|
0.035
|
|
4
|
Inappropriate location of medication or look-alike medication
|
7 (12.7 %)
|
40 (12.6 %)
|
1.000
|
|
5
|
Interruption or distraction when preparing or administering medication
|
8 (14.5 %)
|
22 (6.9 %)
|
0.064
|
|
6
|
Inadequate technique or pharmaceutical service
|
2 (3.6 %)
|
23 (7.3 %)
|
0.557
|
|
7
|
Pressure from patient/family or other staff members to satisfy the patient’s immediate needs
|
2 (3.6 %)
|
21 (6.6 %)
|
0.551
|
|
8
|
Administration in an emergency situation
|
1 (1.8 %)
|
6 (1.9 %)
|
1.000
|
