Patient factors | Â | Frequency (%) | Â | Frequency (%) |
Cognitive factors (N = 34) | Perception/understanding | 25 (73.53) |  |  |
Knowledge based/problem solving | 9 (26.47) | Failure to synthesize/ act on available information | 2 (22.22) | |
Problem with complexity | 7 (77.78) | |||
Performance factors (N = 1) | Technical error in execution (physical-skill based) | 1 (100) | Lapse error | 1 (100) |
Behavior factors (N = 8) | Attention issues | 6 (75) | Distraction/Inattention | 1 |
Absent mindedness | 5 | |||
Fatigue/exhaustion | 2 (25) | Â | Â | |
Communication factors (N = 35) | Communication method | 29 (82.85) | Verbal communication | 29 (82.85) |
Communication with staff | 6 (17.15) | Â | Â | |
Disease related factors (N = 2) | International classification of disease | 2 (100) |  |  |
Emotional factors (N = 7) | – | 7 (100) |  |  |
Social factors (N = 30) | – | 30 (100) |  |  |
Staff factors | Â | Frequency (%) | Â | Frequency (%) |
Cognitive factor (N = 99) | Perception/understanding | 7 (7.07) |  |  |
Knowledge based/problem solving | 75 (75.75) | Failure to synthesize/act on available information | 66 (88) | |
Problems with causality | 2 (2.67) | |||
Problems with complexity | 7 (9.33) | |||
Illusory correlation | 3 (3.03) | Â | Â | |
Halo effect | 14 (14.14) | Â | Â | |
Performance factors (N = 111) | Technical error in execution (physical-skill based) | 90 (81.08) | Slips error | 22 (24.44) |
lapse error | 68 (75.56) | |||
 | Rule based | 3 (2.7) | Misapplication of good rules | 2 (66.67) |
Application of bad rules | 1 (33.33) | |||
 | Selectivity | 3 (2.7) |  |  |
 | Biased reviewing | 15 (13.51) |  |  |
Behavioral factors (N = 150) | Attention issues | 50 (33.33) | Distraction/inattention | 33 (66) |
Absent-mindedness | 16 (32) | |||
Over attention | 1 (2) | |||
Fatigue/exhaustion | 40 (26.67) | Â | Â | |
Overconfidence | 1 (0.67) | Â | ||
 | Non-compliance | 55 (36.67) |  |  |
Communication factors (N = 58) | Communication method | 47 (81.03) | Paper based | 39 (82.97) |
Electronic | 1 (2.13) | |||
Verbal | 7 (14.89) | |||
Communication with staff | 3 (5.17) | Â | Â | |
Communication with patients | 8 (13.80) | Â | Â | |
Organizational factors (N = 82) | Organization of teams | 25(100) |  |  |
Resources or workload | 57(100) | Â | Â | |
External factors (N = 1) | Products, technology or infrastructure | 1(100) |  |  |