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Table 3 Factors contributing towards the occurrence of incidents and their severity index

From: A cross-sectional study: medication safety among cancer in-patients in tertiary care hospitals in KPK, Pakistan

  Site 1 (CPOE) Site 2 (HWP)
No. % Mean 95% CI Sig. (2-tailed) No. % Mean 95% CI Sig. (2-tailed) Total
U L U L
Contributing factors
 Noise level 8 1.3 0.01 0.00 0.02 0.005 8
 Staff training 198 33.6 0.341 0.30 0.38 0.000 147 24.3 0.24 0.21 0.28 0.000 345
 Staffing 4 0.7 0.007 0.00 0.01 0.045 49 8.1 0.08 0.06 0.10 0.000 53
 Patient counseling 19 3.2 0.032 0.02 0.05 0.000 34 5.6 0.05 0.04 0.07 0.000 53
 Nursing floor or pharmacy stock 7 1.2 0.012 0.00 0.02 0.008 24 4 0.04 0.02 0.06 0.000 31
 Frequent interruptions and distractions 57 9.7 0.097 0.07 0.12 0.000 44 7.3 0.07 0.05 0.09 0.000 101
 System covering patient care 88 14.9 0.149 0.12 0.18 0.000 222 36.6 0.36 0.32 0.40 0.000 310
 Lack of availability of HCPs*b 8 1.4 0.014 0.00 0.02 0.005 35 5.8 0.06 0.04 0.08 0.000 43
 Policies and procedures 43 7.3 0.073 0.05 0.09 0.000 61 10.1 0.10 0.08 0.13 0.000 104
 Communication systems 14 2.4 0.024 0.01 0.04 0.000 123 20.3 0.21 0.17 0.24 0.000 137
 Hand written medication orders 67 11.1 0.11 0.08 0.13 0.000 67
 Assignment of inexperienced personnel 7 1.2 0.012 0.00 0.02 0.008 99 16.3 0.16 0.13 0.19 0.000 106
Others (breakup) 464 78.8 0.788 0.75 0.82 0.000 416 68.6 0.68 0.65 0.72 0.000 880
     MAR*c maintenance in hard 16 2.6 0.03 0.01 0.04 0.000 16
     PMR*d in hard form 2 0.3 0.00 0.00 0.01 0.157 2
     Cross checking practice 28 4.8 0.048 0.03 0.06 0.000 57 9.4 0.10 0.07 0.12 0.000 85
     Lack of interdisciplinary approach 78 12.9 0.13 0.10 0.16 0.000 78
     Task performed by wrong personnel 1 0.2 0.002 0.00 0.01 0.318 10 1.7 0.02 0.01 0.03 0.002 11
     Missing documented protocols 3 0.5 0.01 0.00 0.01 0.083 3
     Prescribing practices 261 44.3 0.443 0.40 0.48 0.000 248 40.9 0.41 0.37 0.45 0.000 509
     Lack or delay of culture sensitivity tests 17 2.8 0.03 0.02 0.05 0.000 17
     Staff attitude 92 15.6 0.177 0.14 0.21 0.000 95 15.7 0.16 0.13 0.19 0.000 187
     Lack of updated knowledge 126 21.4 0.214 0.18 0.25 0.000 23 3.8 0.04 0.02 0.05 0.000 149
Total 1417 1878 3295
Patient outcome according to severity index
 No error/Category A*e 14 2.4 0.02 0.01 0.04 0.000 7 1.1 0.00 0.00 0.01 0.157 21
 Error, but no harm 554 94.1 1.76 1.07 1.82 0.000 376 62.1 1.51 1.41 1.61 0.000 930
 Category B*f 146 24.8 24 4 170
 Category C*g 334 56.7 163 26.9 497
 Category D*h 74 12.6 189 31.2 263
Error, and caused harm 21 3.6 0.04 0.02 0.05 0.000 221 36.5 0.56 0.50 0.63 0.000 242
Category E*i 21 3.6 115 19 136
Category F*j 90 14.9 90
Category G*k 15 2.5 15
Category H*l 1 0.2 1
Error, and caused death/ Category I*m 2 0.3 0.02 0.00 0.04 0.023 2
Total 589 606 1195
  1. DRPs*a Drug related problems, HCPs*b Health care professionals, MAR*c Medication administration record, PMR*d Patient medication record. Category A*e: Circumstances or events that have the capacity to cause error, Category B*f: An error occurred but the error did not reach the patient, Category C*g: An error occurred that reached the patient, but did not cause patient harm, Category D*h: Error occurred, reached patient, require monitoring to ensure no harm is occurred and/or require intervention to prevent harm, Category E*I: Error occurred, resulting or contributing to temporary harm to the patient, requiring intervention, Category F*j: Error occurred, contributing to or resulting in temporary harm to the patient, and requiring initial or prolongation of hospitalization, Category G*k: Error occurred, contributing to resulting in permanent patient harm, Category H*l: Error occurred, requiring intervention to sustain life, and Category I*m: Error occurred, resulting in death of the patient
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