High volume Poor handinits Reference Cheragi Inexperienced staff Unfamiliar with environment:- eng bedselty challenge patent populations lack of follow-up lack of appropriate monitors lack of policy enforcement medically complex patient Not enoph means of patent Identifiers e g picture inadequate information flow Staff's patterns and work flow Communication problems lack of training Interruptions Ignore or overlookf ff. medical histories Similar name sharp the same - Date the Same booth cate you have wondered, "What are the InUS! CIBI INQUIVAN