Table 3 A multidimensional analysis of errors categorised according to both the amplified version of GEMS and the inductively-developed key subject areas
From: Exploring patterns of error in acute care using framework analysis
Key subject area | Amplified version of Reason’s generic error modelling system (GEMS) | Intention not established | TOTALS | |||||
|---|---|---|---|---|---|---|---|---|
Skill-based slips/lapses | Rule-based mistakes | Knowledge-based mistakes | Violations | Compound errors | Submission errors | |||
Hospital systems | 1 | 24 | 13 | 3 | 0 | 0 | 11 | 52 |
Infection control | 1 | 0 | 0 | 0 | 0 | 0 | 18 | 19 |
Prioritisation | 1 | 10 | 0 | 3 | 0 | 2 | 6 | 22 |
Procedural skills | 18 | 0 | 12 | 0 | 1 | 0 | 3 | 34 |
Situation awareness | 20 | 9 | 8 | 1 | 19 | 1 | 11 | 69 |
Treatment | 2 | 12 | 6 | 0 | 0 | 1 | 2 | 23 |
Communication | 11 | 0 | 1 | 1 | 1 | 1 | 2 | 17 |
Ethical principles in practice | 0 | 6 | 0 | 1 | 0 | 0 | 0 | 7 |
TOTALS | 54 | 61 | 40 | 9 | 21 | 5 | 53 | 243 |