Factors contributing to the incident (n = 1911)*
| Factors | No |
|---|---|
| *More than one factor was nominated in some reports. | |
| Error of judgement | 240 |
| Inattention | 211 |
| Haste | 200 |
| Communication problem | 163 |
| Fault of technique | 132 |
| Inexperience | 126 |
| Failure to check equipment | 98 |
| Drug label | 96 |
| Preoperative patient assessment inadequate/incorrect | 75 |
| Fatigue | 59 |
| Preoperative patient preparation inadequate/incorrect | 55 |
| Distraction | 54 |
| Unfamiliar environment or equipment | 35 |
| Inadequate assistance | 26 |
| Monitor problem | 26 |
| Pressure to proceed | 22 |
| Surgical team contribution | 22 |
| Relief anaesthetist or staff change | 19 |
| Sick patient | 14 |
| Lack of monitor | 13 |
| Lack of facility | 9 |
| Sick anaesthetist | 6 |
| Other equipment problems | 46 |
| Other stress | 27 |
| All other factors | 137 |