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Table 2 Systems failures and practitioner-based errors identified by the peer review process

From: Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process

Systems failures (n = 188) N (%) Practitioner-based errors (n = 96) N (%)
ED teamwork failures 79 (42) Cognitive errors 65 (68)
Hospital teamwork failures 59 (31) Major cognitive errors 24 (25)
Boarded patients 26 (14) Missed radiographic findings 4 (4)
ED work environment failures 14 (7) Policy deviations 3 (3)
Hospital work environment failures 6 (3) Procedural errors 0 (0)
Triage failures 4 (2)