Research Staff Coding of 54 Patient Reports of Medical Errors Using the ASIPS DMO Taxonomy*
| Characteristic | No. (%) |
|---|---|
| Participants involved in mistake | |
| Physicians | 36 (62) |
| Nonphysician providers and nurses | 23 (40) |
| Third party | 23 (40) |
| Mistake settings | |
| Hospitals | 19 (33) |
| Ambulatory offices | 12 (21) |
| Emergency departments | 8 (14) |
| Outpatient diagnostic facilities | 6 (10) |
| Pharmacies | 6 (10) |
| Laboratories | 2 (3) |
| Type of mistake | |
| Clinical event | 36 (62) |
| Communication errors | 23 (40) |
| Medication errors | 23 (40) |
| Cause of mistake | |
| Clinical knowledge or skill | 7 (12) |
| Errors in judgment | 6 (10) |
| Distraction or inattention | 6 (10) |
| System malfunction, system not present | 3 (5) |
| Resource not available | 2 (3) |
| Failure in information retrieval | 1 (2) |
| Could not determine | 35 (60) |
| Outcome interventions | |
| No intervention needed | 8 (14) |
| Repeated procedures | 14 (24) |
| Medication modification | 6 (10) |
| Could not determine | 20 (35) |
| Types of outcomes from mistake | |
| No change in health status of patient | 24 (41) |
| Temporary impairment | 9 (16) |
| Permanent impairment | 4 (7) |
| Personal inconvenience | 9 (16) |
| Discomfort | 27 (47) |
| New diagnosis resulting from mistake | 4 (7) |
| Death | 4 (7) |
| Could not determine | 1 (2) |
* For any axis, more than 1 code can be assigned.