Table 5.

Contributory Factors.

Contributory factor	Number of cases (%) N = 27
Knowledge and skills	25 (93%)
Complexity of condition	20 (74%)
Verbal and written communication	18 (67%)
Maintenance and availability of equipment	17 (63%)
Availability and use of protocols	16 (59%)
Availability of test results	15 (56%)
Staffing levels	13 (48%)
Financial resources and constraints	11 (41%)
Failure of team leadership	8 (30%)
Policy standards and goals	6 (22%)
Patterns in workload/shift	3 (11%)
Administrative and managerial support	3 (11%)
Safety culture and priorities	2 (7%)
Willingness to seek help	1 (4%)
Patient personality and social factors	1 (4%)