Table 1.

Contributory factors based on Reason’s accident causation model, n = 5104

Active failures (mistakes), n = 3085	% (n)
Skill based mistakes	21.9 (675)
Knowledge based mistakes	4.0 (124)
Technology based mistakes	2.0 (62)
Others	2.0 (62)
Not enough information for classification	69.9 (2159)
Active failures (slips), n = 774
Incomplete order	36.9 (286)
Selecting a wrong medication	35.6 (276)
Selecting a wrong dose	5.5 (43)
Wrong labeling	3.1 (24)
Look alike, sound alike medication	3.1 (24)
Others	8.0 (62)
Not enough information for classification	10.7 (83)
Active failures (lapses), n = 590
Missing information (route/age/dose/weight etc.)	66.9 (395)
Omission	23.8 (141)
Failure to collect medication from pharmacy	2.0 (12)
Others	1.2 (7)
Not enough information for classification	6.1 (36)
Active failures (violations), n = 217
Noncompliance (policy/procedure/orders)	94.0 (203)
Ordering contraindicated medication	3.2 (7)
Patient or caregiver	1.0 (2)
Others	1.3 (3)
Not enough information for classification	1.0 (2)
Error provoking conditions, n = 424
Lack of knowledge	34.6 (148)
Reconciliation	17.9 (76)
Technology based errors (Cerner issues)	6.8 (29)
Communication problems	2.1 (9)
Environment factors	2.1 (9)
Others	25.8 (110)
Not enough information for classification	10.1 (43)
Latent factors, n = 2
Organizational factors	100 (2)