Table 1

Error producing conditions (n=136) relating to 85 human errors (mistakes, slips and lapses)

Error producing conditionNo (%) of human errorsFactors
Handling technology67 (79%)Lack of knowledge, routine and experience in:

  • drug preparation (n=41)

  • drug administration (n=16)

 Inadequate use of technology, e.g. drug charts (n=10)
Design of technology27 (32%)Ambiguous manufacturer leaflets (n=3) 
 Unsuitable working environment (n=5) 
 Design of drug vial presentations/equipment (n=14) 
 Unsuitable preparation procedures (n=5)

Communication14 (16%)Communication problems between:

  • nurses (n=10)

  • nurses and pharmacists (n=1)

  • doctors and other health professionals, e.g. ambiguous prescriptions (n=3)

Workload13 (15%)Several tasks at the same time (n=7) 
 End of shift (n=3) 
 Lack of qualified staff (n=3) 

Patient related factors8 (9%)Limited venous access (n=6) 
 Non-cooperative patient (n=2) 

Supervision5 (6%)Lack of supervision of student nurse/agency nurse (n=5)
Other factors2 (2%)Trying to save disposable equipment (n=2)