Table 3 Provider factors identifiable in incident reports (weighted)*
SubcategoriesDefinitionNo (%)
Any provider factorsAmong all reports, those having at least one provider factor present1786 (46)
Any classifiable provider factorsAmong reports having provider factors, those having at least one provider factor that was classifiable at the broadest subcategory level or lower938 (53)
Types of provider factorsAmong reports having at least one classifiable provider factor, types of factors present
Skill-based errorsActions unconsciously deviated from intentions due to execution failures485 (52)
    SlipActions deviated from intentions due to inattention or inadvertent movement348 (37)
    LapseUnconsciously forgetting something planned145 (15)
Ruled-based mistakesIncorrect application of existing rules when solving a problem141 (15)
    Application incorrectApplying a rule that is valid but only under other circumstances23 (2.5)
    Rule incorrectApplying a rule that is never correct120 (13)
Knowledge-based mistakesIncorrect application of knowledge when reasoning through a problem88 (9.4)
    Incomplete knowledgeInadequate knowledge of disease, treatment or resources available43 (4.6)
    Reasoning errorFailure to focus attention on important issues, reluctance to relinquish interpretation despite conflicting information, overconfidence, biased interpretation and oversimplification51 (5.4)
Intentional violationsConscious deviation from standard practice276 (29)
    RoutineProvider was knowingly taking short-cuts (often due to time constraints or a culture of low expectations)66 (7.0)
    ExceptionalProvider was forced to violate a rule to solve a problem or to avoid violating a more important rule207 (22)
    SabotageConscious violation with malicious intent3 (0.3)
  • *Weighted to reflect incident reports for all patients discharged from the two hospitals.