TABLE 3-7 Distribution of Errors by Proximal Cause and Stage

Proximal Cause

Ordering % (No.)

Transcription and Verification % (No.)

Dispensing % (No.)

Administration % (No.)

All % (No.)

Lack of knowledge of the drug

36

(47)

15

(6)

0

(0)

15

(19)

22

(72)

Lack of information about the patient

24

(31)

10

(4)

0

(0)

10

(13)

14

(48)

Rule violations

19

(25)

0

(0)

16

(6)

2

(2)

10

(33)

Slips and memory lapses

11

(14)

0

(0)

0

(0)

12

(15)

9

(29)

Transcription errors

0

(0)

73

(29)

0

(0)

0

(0)

9

(29)

Faulty drug identity checking

0

(0)

0

(0)

29

(11)

10

(13)

7

(24)

Faulty interaction with other services

1

(1)

0

(0)

8

(3)

10

(13)

5

(17)

Faulty dose checking

0

(0)

0

(0)

8

(3)

10

(13)

5

(16)

Infusion pump and parenteral delivery problems

0

(0)

0

(0)

0

(0)

13

(16)

5

(16)

Inadequate monitoring

8

(11)

0

(0)

0

(0)

3

(4)

4

(15)

Drug stocking and delivery problems

0

(0)

0

(0)

29

(11)

0

(0)

3

(11)

Preparation errors

0

(0)

0

(0)

11

(4)

5

(6)

3

(10)

Lack of standardization

0

(0)

0

(0)

0

(0)

6

(8)

2

(8)

Unclassified

1

(1)

3

(1)

0

(0)

3

(4)

2

(6)

TOTALS*

100

(130)

100

(40)

100

(38)

100

(126)

100

(334)

  

*Percentages do not add to 100% due to rounding.

SOURCE: Leape etal., 1995.



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