Factors perceived to have contributed to errors with each product type
| Product type | Perceived contributory factors | ||||||||||||
| Staff error | Inadequate training | Facility/equipment error | Poor quality of starting materials used | Inadequate computer system | Process design | Poor storage/distribution | Staffing level below establishment | Workload above planned capacity | Poor segregation | Distraction/interruption | Not recorded | Total | |
| Cytotoxic adult | 1745 (80.7%) | 75 (3.5%) | 23 (1.1%) | 13 (0.6%) | 55 (2.5%) | 47 (2.2%) | 10 (0.5%) | 51 (2.4%) | 40 (1.9%) | 17 (0.8%) | 58 (2.7%) | 29 (1.3%) | 2163 |
| Cytotoxic paediatric | 98 (64.9%) | 4 (2.7%) | 2 (1.3%) | 2 (1.3%) | 13 (8.6%) | 2 (1.3%) | 0 | 5 (3.3%) | 6 (4%) | 1 (0.7%) | 15 (9.9%) | 3 (2%) | 151 |
| Parenteral nutrition—adult | 621 (77.6%) | 15 (1.9%) | 2 (0.3%) | 1 (0.1%) | 13 (1.6%) | 5 (0.6%) | 11 (1.4%) | 35 (4.4%) | 55 (6.9%) | 4 (0.5%) | 27 (3.4%) | 11 (1.4%) | 800 |
| Parenteral nutrition—paediatric | 155 (68.3%) | 7 (3.1%) | 5 (2.2%) | 3 (1.3%) | 7 (3.1%) | 6 (2.6%) | 1 (0.4%) | 13 (5.7%) | 12 (5.3%) | 2 (0.9%) | 14 (6.2%) | 2 (0.9%) | 227 |
| Other intravenous additive | 1161 (80.1%) | 61 (4.2%) | 10 (0.7%) | 3 (0.2%) | 19 (1.3%) | 24 (1.7%) | 14 (1%) | 46 (3.2%) | 55 (3.8%) | 1 (0.1%) | 34 (2.4%) | 21 (1.5%) | 1449 |
| Other prefilled syringes | 288 (71.1%) | 25 (6.2%) | 0 | 0 | 3 (0.7%) | 4 (1%) | 3 (0.7%) | 17 (4.2%) | 5 (1.2%) | 3 (0.7%) | 52 (12.8%) | 5 (1.2%) | 405 |
| Other | 201 (78.2%) | 12 (4.7%) | 2 (0.8%) | 0 | 0 | 8 (3.1%) | 2 (0.8%) | 3 (1.2%) | 3 (1.2%) | 5 (2%) | 19 (7.4%) | 2 (0.8%) | 257 |
| Not recorded | 42 (60%) | 4 (5.7%) | 0 | 0 | 0 | 0 | 1 (1.4%) | 1 (1.4%) | 0 | 0 | 20 (28.6%) | 2 (2.9%) | 70 |
| Total | 4311 (78.1%) | 203 (3.7%) | 44 (0.8%) | 22 (0.4%) | 110 (2%) | 96 (1.7%) | 42 (0.8%) | 171 (3.1%) | 176 (3.2%) | 33 (0.6%) | 239 (4.3%) | 75 (1.4%) | 5522 |