Table 2 Shows connection between themes, problem groups and Ishikawa categories. Includes number of reports analyzed
Problem groups | Themes | Ishikawa | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The problem that causes the event described | Number of reports concerned | A. Medical staff orientation, onboarding and competence requirements | B.Human resources on duty | C. Electronic medical records and information transfer | D. Medication documentation system | E. Interprofessional collaboration and teamwork | F. Professional resources for specific patient groups* | Equipment | Process | People | Materials | Environment | Management |
1. Insufficient introduction/lack of guidelines and protocols or adherence to following them | 28 | X | X | X | X | X | X | X | X | ||||
2. Insufficient human resources available | 18 | X | X | X | X | X | X | X | X | X | |||
3. Deficient professional skills | 62 | X | X | X | X | X | X | X | X | X | |||
4. Medication Management Deficiencies | 70 | X | X | X | X | X | X | X | X | X | X | X | X |
5. Incomplete information transfer from ED | 44 | X | X | X | X | X | X | X | X | X | X | X | |
6. Language proficiency | 6 | X | X | X | X | X | X | X | X | ||||
7. Unprofessional behavior | 4 | X | X | X | X | X | X | X | X | X | |||
8. Identification error | 12 | X | X | X | X | X | X | X | |||||
9. Patient-dependent problem | 13 | X | X | X | X | X | X | X | X | ||||
10.Other | 13 | X | X | X | X | X | X | X | |||||
TOTAL | 270 | ||||||||||||