Table 4 Rate of incidents at different settings and stages; their preventability and interventions
Variable | Site 1 (CPOE) | Site 2 (HWP) | Total | |||
|---|---|---|---|---|---|---|
N | % | N | % | N | % | |
Setting of initial incidents | ||||||
 Oncology ward | 287 | 48.7 | 294 | 48.5 | 581 | 97.2 |
 Pharmacy | 12 | 2 | 28 | 4.6 | 40 | 6.6 |
 Prescriber’s Office | 285 | 48.4 | 269 | 44.4 | 554 | 92.8 |
 Patient home | – | – | 10 | 1.7 | 10 | 1.7 |
 Other | 5 | 0.8 | 5 | 0.8 | 10 | 1.6 |
Stages of initial error | ||||||
 Physician | 516 | 87.6 | 495 | 81.7 | 1011 | 169.3 |
  Consultant | 372 | 63.2 | 389 | 64.2 | 761 | 127.4 |
  Medical Officer | 139 | 23.8 | 96 | 15.8 | 235 | 39.6 |
  Fellow | – | – | 10 | 1.7 | 10 | 1.7 |
  Resident | 5 | 0.6 | – | – | 5 | 0.6 |
 Pharmacist | 39 | 6.6 | 21 | 3.5 | 56 | 10.1 |
  Prescription receiving or checking | 29 | 4.9 | 15 | 2.5 | 43 | 7.4 |
  Prescription filling | 9 | 1.5 | 6 | 1 | 12 | 2.5 |
  Dispensing | 1 | 0.2 | – | – | 1 | 0.2 |
 Nurse | 25 | 4.3 | 75 | 12.3 | 100 | 16.6 |
  Medication received | 24 | 4.1 | 62 | 10.2 | 86 | 14.3 |
  Administered | 1 | 0.2 | 13 | 2.1 | 14 | 2.3 |
Patient Care Giver | 14 | 2.4 | 5 | 0.8 | 19 | 3.2 |
Other | 2 | 0.3 | 4 | 0.7 | 6 | 1 |
 Support personnel | 2 | 0.3 | – | – | 2 | 0.3 |
  Health Profession Students | – | – | 1 | 0.2 | 1 | 0.2 |
  Physician assistant | – | – | 3 | 0.5 | 3 | 0.5 |
 Unknown | – | – | 10 | 1.7 | 10 | 1.7 |
Stage of error discovery | ||||||
 Physician | 48 | 8.1 | 24 | 4 | 72 | 12.1 |
  Consultant | 29 | 4.9 | – | – | 29 | 4.9 |
  Medical Officer | 19 | 3.2 | 13 | 2.1 | 32 | 5.3 |
  Fellow | – | – | 11 | 1.8 | 11 | 1.8 |
  Resident | – | – | – | – | – | – |
 Pharmacist | 482 | 81.8 | 14 | 2.3 | 496 | 84.1 |
  Prescription receiving or checking | 378 | 64.2 | 11 | 2.1 | 389 | 66.3 |
  Prescription filling | 90 | 15.3 | 3 | 0.5 | 93 | 15.8 |
  Dispensing | 14 | 2.4 | – | – | 14 | 2.4 |
 Nurse | 15 | 2.6 | 30 | 5 | 45 | 7.6 |
  Medication received | 8 | 1.4 | 24 | 4 | 32 | 5.4 |
  Administered | 7 | 1.2 | 6 | 1 | 13 | 2.2 |
Patient care giver | – | – | 1 | 0.2 | 1 | 0.2 |
Other | 44 | 7.5 | 536 | 88.4 | 580 | 95.9 |
  Health Profession Students | – | – | 9 | 1.5 | 9 | 1.5 |
  Support personnel | 1 | 0.2 | – | – | 1 | 0.2 |
  Physician Assistant | 1 | 0.2 | – | – | 1 | 0.2 |
  Primary Investigator (PI) | 42 | 7.1 | 527 | 86.9 | 569 | 94 |
Unknown | – | – | 1 | 0.2 | 1 | 0.2 |
Rate of MEsa without harm and potential ADEsb | ||||||
 MEs without harm | 574 | 97.5 | 20 | 3.3 | 594 | 100.8 |
 Potential ADEs | 15 | 2.5 | 586 | 96.7 | 601 | 99.2 |
Preventability of the event | ||||||
 Preventability | 582 | 98.8 | 601 | 99.2 | 1183 | 198 |
 Not-preventable | 7 | 1.2 | 5 | 0.8 | 12 | 2 |
Total | 589 | 100 | 606 | 100 | 1195 | Â |
Intervention | ||||||
 Medical intervention | 533 | 90.5 | 48 | 7.9 | 581 | 98.4 |