TableĀ 3

Top 25 why did it happen? Codes

Multiple systems (two or more electronic systems)1211
Use of system or SIG abbreviations494
Failure to follow established procedures or protocol480
Profiling Issues: failure to perform or use correctly443
Inexperienced end user415
Lack of computer training/system knowledge325
Typing error206
Hybrid system (electronic and paper)205
Communication issues200
System limitations/inadequacy: routing/mapping issue186
Lack of clinical knowledge186
Medication reconciliation issue184
Alert ignored/overridden153
Nursing administration issues149
Pharmacy order entry problems/issues134
Transcriptions (copy/paste)133
Comments field free text confusing/confusion121
eMAR/MAR issues119
Order set/template/protocol issues113
Drug dictionary miscode/out-of-date drug information109
Patient identification issue95
Initial vs continuing order issue93
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.