Top 25 why did it happen? Codes
| Code | N |
|---|---|
| Unknown | 5326 |
| Multiple systems (two or more electronic systems) | 1211 |
| Use of system or SIG abbreviations | 494 |
| Failure to follow established procedures or protocol | 480 |
| Profiling Issues: failure to perform or use correctly | 443 |
| Inexperienced end user | 415 |
| Lack of computer training/system knowledge | 325 |
| Typing error | 206 |
| Hybrid system (electronic and paper) | 205 |
| Communication issues | 200 |
| System limitations/inadequacy: routing/mapping issue | 186 |
| Lack of clinical knowledge | 186 |
| Medication reconciliation issue | 184 |
| Alert ignored/overridden | 153 |
| Nursing administration issues | 149 |
| Pharmacy order entry problems/issues | 134 |
| Transcriptions (copy/paste) | 133 |
| Comments field free text confusing/confusion | 121 |
| eMAR/MAR issues | 119 |
| Order set/template/protocol issues | 113 |
| Drug dictionary miscode/out-of-date drug information | 109 |
| Patient identification issue | 95 |
| Initial vs continuing order issue | 93 |
| Patient transferred (within hospital) | 91 |
| Misinterpretation of order(s) | 72 |
eMAR, electronic medication administration record; MAR, medication administration record; SIG, sig code for directions on how to take a medication.