Figure 1. Examples of cascade of errors revealed in physicians’ descriptions of incidents.

Treatment (TR) = errors in administering treatments, medications, immunizations, and care plans; diagnosis (DX) = errors in screening, diagnostic examination and testing, and interpretation of findings; informational communication (IC) = errors in processing messages, instructions, and medical record data; personal communication (PC) = errors in interpersonal communication among providers and patients; CBC = complete blood count.