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Table 1 Causal mechanisms associated with near miss reports originating in the ICU, based on Joint Commission patient safety event taxonomy

From: An analysis of near misses identified by anesthesia providers in the intensive care unit

  n %
Skill based: failure to execute a task appropriately 4 16 %
Poor communication 3 12 %
Rule based: failure to perform routine task 3 12 %
Poor culture of safety 2 8 %
Equipment malfunction 2 8 %
Inadequate resources 1 4 %
Time pressure 1 4 %
Faulty design 1 4 %
Faulty construction 1 4 %
Obsolescence 1 4 %
Equipment unavailability 1 4 %
Technical failures beyond control of the institution 1 4 %
Insufficient supervision 1 4 %
Failures related to patient factors beyond control of the institution 1 4 %
Intentional violation 1 4 %
Insufficient training 1 4 %
Total 25 100 %