Table 3.
A multidimensional analysis of errors categorised according to both the amplified version of GEMS and the inductively-developed key subject areas
| Key subject area | Amplified version of Reason’s generic error modelling system (GEMS) | Intention not established | TOTALS | |||||
|---|---|---|---|---|---|---|---|---|
| Skill-based slips/lapses | Rule-based mistakes | Knowledge-based mistakes | Violations | Compound errors | Submission errors | |||
| Hospital systems | 1 | 24 | 13 | 3 | 0 | 0 | 11 | 52 |
| Infection control | 1 | 0 | 0 | 0 | 0 | 0 | 18 | 19 |
| Prioritisation | 1 | 10 | 0 | 3 | 0 | 2 | 6 | 22 |
| Procedural skills | 18 | 0 | 12 | 0 | 1 | 0 | 3 | 34 |
| Situation awareness | 20 | 9 | 8 | 1 | 19 | 1 | 11 | 69 |
| Treatment | 2 | 12 | 6 | 0 | 0 | 1 | 2 | 23 |
| Communication | 11 | 0 | 1 | 1 | 1 | 1 | 2 | 17 |
| Ethical principles in practice | 0 | 6 | 0 | 1 | 0 | 0 | 0 | 7 |
| TOTALS | 54 | 61 | 40 | 9 | 21 | 5 | 53 | 243 |
The bold numbers indicate patterns within the dataset.