Table 4.
Events Reported by Physician and Nurse Subjects (N = 76)
| Res MD | Att MD | Nurse | |
|---|---|---|---|
| Personal responsibility | |||
| Yes (any degree) | 17 (71%) | 3 (19%) | 16 (44%) |
| Minimal | 1 (4%) | 1 (6%) | 5 (14%) |
| Somewhat | 4 (17%) | 1 (6%) | 3 (8%) |
| Mostly | 2 (8%) | 0 | 1 (3%) |
| Completely | 10 (42%) | 1 (6%) | 7 (19%) |
| Event Result | |||
| Error made, med not given | 18 (64%) | 9 (47%) | 21 (47%) |
| Error made, med given | 5 (18%) | 5 (26%) | 12 (27%) |
| No harm | 3 (11%) | 4 (21%) | 11 (24%) |
| No harm, monitoring | 1 (4%) | 0 | 0 |
| Temporary harm | 0 | 0 | 1 (2%) |
| Temporary harm with treatment | 1 (4%) | 1 (5%) | 0 |
| Process Step Involved | |||
| Prescribing | 12 (57%) | 12 (71%) | 6 (19%) |
| Transcribing | 3 (14%) | 1 (6%) | 5 (16%) |
| Dispensing | 2 (10%) | 1 (6%) | 4 (13%) |
| Administration | 3 (14%) | 2 12%) | 7 (22%) |
| Delays | 0 | 0 | 5 (16%) |
| Administration-pump | 0 | 0 | 2 (6%) |
| Other | 1 (5%) | 1 (6%) | 3 (9%) |
| Causes or Factors | |||
| Communication | 7 (31%) | 5 (29%) | 8 (24%) |
| Information systems | 3 (13%) | 0 | 2 (6%) |
| Equipment or devices | 0 | 0 | 3 (9%) |
| Patient or clinical context | 1 (4%) | 0 | 0 |
| Clinician | 7 (31%) | 7 (41%) | 7 (21%) |
| Staffing and workload | 1 (4%) | 2 (12%) | 2 (6%) |
| Organizational | 2 (9%) | 1 (6%) | 5 (15%) |
| Other | 2 (9%) | 2 (12%) | 6 (18%) |