| Site 1 (CPOE) | Site 2 (HWP) | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
No. | % | Mean | 95% CI | Sig. (2-tailed) | No. | % | Mean | 95% CI | Sig. (2-tailed) | Total | |||
U | L | U | L | ||||||||||
Contributing factors | |||||||||||||
 Noise level | – | – | – | – | – | – | 8 | 1.3 | 0.01 | 0.00 | 0.02 | 0.005 | 8 |
 Staff training | 198 | 33.6 | 0.341 | 0.30 | 0.38 | 0.000 | 147 | 24.3 | 0.24 | 0.21 | 0.28 | 0.000 | 345 |
 Staffing | 4 | 0.7 | 0.007 | 0.00 | 0.01 | 0.045 | 49 | 8.1 | 0.08 | 0.06 | 0.10 | 0.000 | 53 |
 Patient counseling | 19 | 3.2 | 0.032 | 0.02 | 0.05 | 0.000 | 34 | 5.6 | 0.05 | 0.04 | 0.07 | 0.000 | 53 |
 Nursing floor or pharmacy stock | 7 | 1.2 | 0.012 | 0.00 | 0.02 | 0.008 | 24 | 4 | 0.04 | 0.02 | 0.06 | 0.000 | 31 |
 Frequent interruptions and distractions | 57 | 9.7 | 0.097 | 0.07 | 0.12 | 0.000 | 44 | 7.3 | 0.07 | 0.05 | 0.09 | 0.000 | 101 |
 System covering patient care | 88 | 14.9 | 0.149 | 0.12 | 0.18 | 0.000 | 222 | 36.6 | 0.36 | 0.32 | 0.40 | 0.000 | 310 |
 Lack of availability of HCPs*b | 8 | 1.4 | 0.014 | 0.00 | 0.02 | 0.005 | 35 | 5.8 | 0.06 | 0.04 | 0.08 | 0.000 | 43 |
 Policies and procedures | 43 | 7.3 | 0.073 | 0.05 | 0.09 | 0.000 | 61 | 10.1 | 0.10 | 0.08 | 0.13 | 0.000 | 104 |
 Communication systems | 14 | 2.4 | 0.024 | 0.01 | 0.04 | 0.000 | 123 | 20.3 | 0.21 | 0.17 | 0.24 | 0.000 | 137 |
 Hand written medication orders | – | – | – | – | – | – | 67 | 11.1 | 0.11 | 0.08 | 0.13 | 0.000 | 67 |
 Assignment of inexperienced personnel | 7 | 1.2 | 0.012 | 0.00 | 0.02 | 0.008 | 99 | 16.3 | 0.16 | 0.13 | 0.19 | 0.000 | 106 |
Others (breakup) | 464 | 78.8 | 0.788 | 0.75 | 0.82 | 0.000 | 416 | 68.6 | 0.68 | 0.65 | 0.72 | 0.000 | 880 |
   MAR*c maintenance in hard | – | – | – | – | – | – | 16 | 2.6 | 0.03 | 0.01 | 0.04 | 0.000 | 16 |
   PMR*d in hard form | – | – | – | – | – | – | 2 | 0.3 | 0.00 | 0.00 | 0.01 | 0.157 | 2 |
   Cross checking practice | 28 | 4.8 | 0.048 | 0.03 | 0.06 | 0.000 | 57 | 9.4 | 0.10 | 0.07 | 0.12 | 0.000 | 85 |
   Lack of interdisciplinary approach | – | – | – | – | – | – | 78 | 12.9 | 0.13 | 0.10 | 0.16 | 0.000 | 78 |
   Task performed by wrong personnel | 1 | 0.2 | 0.002 | 0.00 | 0.01 | 0.318 | 10 | 1.7 | 0.02 | 0.01 | 0.03 | 0.002 | 11 |
   Missing documented protocols | – | – | – | – | – | – | 3 | 0.5 | 0.01 | 0.00 | 0.01 | 0.083 | 3 |
   Prescribing practices | 261 | 44.3 | 0.443 | 0.40 | 0.48 | 0.000 | 248 | 40.9 | 0.41 | 0.37 | 0.45 | 0.000 | 509 |
   Lack or delay of culture sensitivity tests | – | – | – | – | – | – | 17 | 2.8 | 0.03 | 0.02 | 0.05 | 0.000 | 17 |
   Staff attitude | 92 | 15.6 | 0.177 | 0.14 | 0.21 | 0.000 | 95 | 15.7 | 0.16 | 0.13 | 0.19 | 0.000 | 187 |
   Lack of updated knowledge | 126 | 21.4 | 0.214 | 0.18 | 0.25 | 0.000 | 23 | 3.8 | 0.04 | 0.02 | 0.05 | 0.000 | 149 |
Total | 1417 | – | – | – | – | – | 1878 | – | – | – | – | – | 3295 |
Patient outcome according to severity index | |||||||||||||
 No error/Category A*e | 14 | 2.4 | 0.02 | 0.01 | 0.04 | 0.000 | 7 | 1.1 | 0.00 | 0.00 | 0.01 | 0.157 | 21 |
 Error, but no harm | 554 | 94.1 | 1.76 | 1.07 | 1.82 | 0.000 | 376 | 62.1 | 1.51 | 1.41 | 1.61 | 0.000 | 930 |
 Category B*f | 146 | 24.8 | – | – | – | – | 24 | 4 | – | – | – | – | 170 |
 Category C*g | 334 | 56.7 | – | – | – | – | 163 | 26.9 | – | – | – | – | 497 |
 Category D*h | 74 | 12.6 | – | – | – | – | 189 | 31.2 | – | – | – | – | 263 |
Error, and caused harm | 21 | 3.6 | 0.04 | 0.02 | 0.05 | 0.000 | 221 | 36.5 | 0.56 | 0.50 | 0.63 | 0.000 | 242 |
Category E*i | 21 | 3.6 | – | – | – | – | 115 | 19 | – | – | – | – | 136 |
Category F*j | – | – | – | – | – | – | 90 | 14.9 | – | – | – | – | 90 |
Category G*k | – | – | – | – | – | – | 15 | 2.5 | – | – | – | – | 15 |
Category H*l | – | – | – | – | – | – | 1 | 0.2 | – | – | – | – | 1 |
Error, and caused death/ Category I*m | – | – | – | – | – | – | 2 | 0.3 | 0.02 | 0.00 | 0.04 | 0.023 | 2 |
Total | 589 | – | – | – | – | – | 606 | – | – | – | – | – | 1195 |