Clinical changes at the bedside | 172 | 26.18 | 100 | Equipment/computer-related actions | 73 | 11.11 | 100 |
Unspecified clinical changes | 60 | 9.13 | 34.8 | Electronic template or tool | 24 | 3.65 | 32.9 |
Drug storage | 25 | 3.81 | 14.5 | Unspecified equipment related actions | 18 | 2.74 | 24.7 |
Drug dispensing | 24 | 3.65 | 14.0 | Explore improving/obtaining software/ | 12 | 1.83 | 16.4 |
Explore possibility of changes to the | 22 | 3.35 | 12.8 | hardware | | | |
clinical process | | | | Install/improve software alerts | 7 | 1.07 | 9.6 |
Changing order entry through alerts, | 12 | 1.83 | 7.0 | Hardware acquisition | 4 | 0.61 | 5.5 |
forcing functions | | | | Plan to improve/obtain new software/ | 4 | 0.61 | 5.5 |
Encouraging people to use existing | 10 | 1.52 | 5.8 | hardware | | | |
computer capacity | | | | Update software | 3 | 0.46 | 4.1 |
Inpatient pharmacy medication verification | 7 | 1.07 | 4.1 | Improve software interface | 1 | 0.15 | 1.4 |
Action related to outpatient | 4 | 0.61 | 2.3 | | | | |
medication delivery | | | | Communication actions | 38 | 5.78 | 100 |
Action related to medication scans | 4 | 0.61 | 2.3 | Unspecified communication actions | 25 | 3.81 | 65.8 |
Outpatient verification of medication | 3 | 0.46 | 1.7 | Improve communication with pharmacy | 7 | 1.07 | 18.4 |
Action related to wristband scans | 1 | 0.15 | 0.6 | Improve reporting of equipment/ | 3 | 0.46 | 7.9 |
| | | | software failures | | | |
Policies and procedures | 163 | 24.81 | 100 | Standardise terminology | 2 | 0.30 | 5.3 |
Unspecified changes in policy or procedure | 58 | 8.83 | 35.6 | Improve reporting of events/close calls | 1 | 0.15 | 2.6 |
Medication administration | 35 | 5.33 | 21.5 | | | | |
Medication dispensing | 23 | 3.50 | 14.1 | Data collection/use | 22 | 3.35 | 100 |
Adherence to medication administration | 20 | 3.04 | 12.3 | Assess/analyse data for process for | 11 | 1.67 | 50.1 |
policy | | | | improvement | | | |
Adherence to medication dispensing policy | 11 | 1.67 | 6.8 | Unspecified data collection/use | 6 | 0.91 | 27.3 |
Doctor prescribing/ordering | 9 | 1.37 | 5.5 | Improve data collection process | 5 | 0.76 | 22.8 |
Adherence to doctor prescribing/ordering | 5 | 0.76 | 3.1 | | | | |
policy | | | | Obtain more information/explore options | 21 | 3.20 | 100 |
Improve medication finishing | 2 | 0.30 | 1.2 | | | | |
| | | | Actions not otherwise specified | 25 | 3.81 | 100 |
Training and education actions | 143 | 21.77 | 100 | | | | |
Development/implementation of a cognitive | 34 | 5.18 | 23.8 | | | | |
aid/reminder | | | | | | | |
Unspecified training or education | 32 | 4.87 | 22.4 | | | | |
Medication administration | 24 | 3.65 | 16.8 | | | | |
New policy or procedure | 23 | 3.50 | 16.1 | | | | |
Order finishing and dispensing procedure | 13 | 1.98 | 9.1 | | | | |
Use of equipment | 8 | 1.22 | 5.6 | | | | |
Order entry | 5 | 0.76 | 3.5 | | | | |
Use of alerts | 2 | 0.30 | 1.4 | | | | |
Supervisor training | 2 | 0.30 | 1.4 | | | | |