Table 6 Formulate theories through brainstorming

1. Abbreviations

31. Labeling (hospital’s)

2. Blanket orders

32. Leading zero missing

3. Brand names look alike

33. Measuring device inaccurate/inappropriate

4. Brand names sound alike

34. Monitoring inadequate/lacking

5. Brand/generic names look alike

6. Brand/generic names sound alike

35. Non-formulary drug

36. Non-metric units used

7. Calculation error

37. Packaging/container Design

8. Communication

38. Patient identification failure

9. Contraindicated, drug allergy

39. Preprinted order form

10. Contraindicated, drug/ drug

11. Contraindicated, drug/ food

40. Performance (human) deficit

41. Procedure/Protocol not followed

12. Contraindicated in disease

42. Pump, failure/malfunction

13. Contraindicated in pregnancy/breastfeeding

43. Pump, improper use

14. Decimal point

44. Reconciliation-admission

15. Diluents wrong

45. Reconciliation-discharge

16. Dispensing device involved

46. Reconciliation-transition

17. Documentation inaccurate/lacking

47. Reference material confusing/inaccurate

18. Dosage form confusion

48. Repackaging by hospital

19. Drug distribution system

49. Repackaging by other facility

20. Drug shortage

50. Similar packaging/labeling

21. Equipment design confusing/inadequate

51. Similar products

22. Equipment (not pumps) failure/malfunction

52. Storage proximity

23. Generic names look alike

53. System safeguards inadequate

24. Generic names sound alike

54. Transcription inaccurate /omitted

25. Handwriting illegible/ unclear

55. Unlabeled syringe/container

26. Incorrect medication activation

56. Verbal order confusing/incomplete

27. Information management system

57. Weight missing/inaccurate

28. Knowledge deficit/training Insufficient

58. Written order confusing/incomplete

29. Label (manufacturer’s) design

59. Workflow disruption

30. Label (hospital’s) design