|
Setting of initial incidents
|
|
Oncology ward
|
287
|
48.7
|
294
|
48.5
|
581
|
97.2
|
|
Pharmacy
|
12
|
2
|
28
|
4.6
|
40
|
6.6
|
|
Prescriber’s Office
|
285
|
48.4
|
269
|
44.4
|
554
|
92.8
|
|
Patient home
|
–
|
–
|
10
|
1.7
|
10
|
1.7
|
|
Other
|
5
|
0.8
|
5
|
0.8
|
10
|
1.6
|
|
Stages of initial error
|
|
Physician
|
516
|
87.6
|
495
|
81.7
|
1011
|
169.3
|
|
Consultant
|
372
|
63.2
|
389
|
64.2
|
761
|
127.4
|
|
Medical Officer
|
139
|
23.8
|
96
|
15.8
|
235
|
39.6
|
|
Fellow
|
–
|
–
|
10
|
1.7
|
10
|
1.7
|
|
Resident
|
5
|
0.6
|
–
|
–
|
5
|
0.6
|
|
Pharmacist
|
39
|
6.6
|
21
|
3.5
|
56
|
10.1
|
|
Prescription receiving or checking
|
29
|
4.9
|
15
|
2.5
|
43
|
7.4
|
|
Prescription filling
|
9
|
1.5
|
6
|
1
|
12
|
2.5
|
|
Dispensing
|
1
|
0.2
|
–
|
–
|
1
|
0.2
|
|
Nurse
|
25
|
4.3
|
75
|
12.3
|
100
|
16.6
|
|
Medication received
|
24
|
4.1
|
62
|
10.2
|
86
|
14.3
|
|
Administered
|
1
|
0.2
|
13
|
2.1
|
14
|
2.3
|
|
Patient Care Giver
|
14
|
2.4
|
5
|
0.8
|
19
|
3.2
|
|
Other
|
2
|
0.3
|
4
|
0.7
|
6
|
1
|
|
Support personnel
|
2
|
0.3
|
–
|
–
|
2
|
0.3
|
|
Health Profession Students
|
–
|
–
|
1
|
0.2
|
1
|
0.2
|
|
Physician assistant
|
–
|
–
|
3
|
0.5
|
3
|
0.5
|
|
Unknown
|
–
|
–
|
10
|
1.7
|
10
|
1.7
|
|
Stage of error discovery
|
|
Physician
|
48
|
8.1
|
24
|
4
|
72
|
12.1
|
|
Consultant
|
29
|
4.9
|
–
|
–
|
29
|
4.9
|
|
Medical Officer
|
19
|
3.2
|
13
|
2.1
|
32
|
5.3
|
|
Fellow
|
–
|
–
|
11
|
1.8
|
11
|
1.8
|
|
Resident
|
–
|
–
|
–
|
–
|
–
|
–
|
|
Pharmacist
|
482
|
81.8
|
14
|
2.3
|
496
|
84.1
|
|
Prescription receiving or checking
|
378
|
64.2
|
11
|
2.1
|
389
|
66.3
|
|
Prescription filling
|
90
|
15.3
|
3
|
0.5
|
93
|
15.8
|
|
Dispensing
|
14
|
2.4
|
–
|
–
|
14
|
2.4
|
|
Nurse
|
15
|
2.6
|
30
|
5
|
45
|
7.6
|
|
Medication received
|
8
|
1.4
|
24
|
4
|
32
|
5.4
|
|
Administered
|
7
|
1.2
|
6
|
1
|
13
|
2.2
|
|
Patient care giver
|
–
|
–
|
1
|
0.2
|
1
|
0.2
|
|
Other
|
44
|
7.5
|
536
|
88.4
|
580
|
95.9
|
|
Health Profession Students
|
–
|
–
|
9
|
1.5
|
9
|
1.5
|
|
Support personnel
|
1
|
0.2
|
–
|
–
|
1
|
0.2
|
|
Physician Assistant
|
1
|
0.2
|
–
|
–
|
1
|
0.2
|
|
Primary Investigator (PI)
|
42
|
7.1
|
527
|
86.9
|
569
|
94
|
|
Unknown
|
–
|
–
|
1
|
0.2
|
1
|
0.2
|
|
Rate of MEsa without harm and potential ADEsb
|
|
MEs without harm
|
574
|
97.5
|
20
|
3.3
|
594
|
100.8
|
|
Potential ADEs
|
15
|
2.5
|
586
|
96.7
|
601
|
99.2
|
|
Preventability of the event
|
|
Preventability
|
582
|
98.8
|
601
|
99.2
|
1183
|
198
|
|
Not-preventable
|
7
|
1.2
|
5
|
0.8
|
12
|
2
|
|
Total
|
589
|
100
|
606
|
100
|
1195
| |
|
Intervention
|
|
Medical intervention
|
533
|
90.5
|
48
|
7.9
|
581
|
98.4
|
