
282 R. Mitchell, A. Williamson & B. Molesworth
Table 3. Type of contributing factors identified as involved in
the event.
Contributed to each
incident (n = 498)
Contributing factors (CFs) n % Cases
Equipment 23 4.6
Lack of equipment 7 1.4
Medical equipment failure – design 10 2.0
Medical equipment failure or breakage 5 1.0
Medical equipment not elsewhere classified 1 0.2
Work environment 20 4.0
Staff action factors 176 35.3
Communication or documentation issues 115 23.1
Medical task failure 23 4.6
Monitoring 10 2.0
Delay 14 2.8
Misdiagnosis 5 1.0
Medication issue 8 1.6
Staff action nec
1
1 0.2
Patient 265 53.2
Physical health-pre-existing 219 44.0
Health state 21