Table 3.

Shows results of inductive and analogical reasoning

Event description	Reporters’ perception, or if missing, researchers’ evaluation of the root cause	Theme, the concern involves with	The problem that causes the event described
Orders given by physician were contradictory to organizational guidelines	Physician on call is unfamiliar with hospital wards and departments and guidelines how to report and arrange follow up treatment and document instructions.	A. Medical staff orientation, onboarding and competence requirements E. Interprofessional collaboration and teamwork F. Professional resources for specific patient groupsa	1. Insufficient introduction and either lack of guidelines and protocols or adherence to following them
Physician was not familiar with basic documentation and follow-up instructions
Physician did not know what instructions to follow when discharging a patient to a ward or home
Physician was unfamiliar with hospital wards and departments and how to arrange follow-up treatment and provide instructions
Physician directed the patient’s follow-up to wrong department
The patient was sent to ask the health center for a follow-up examination that cannot be obtained from the health center.
The patient with need for intense follow-up was transferred to ward which has no possibility to take any laboratory tests during the weekend
Physician on-call did not know what telephone to use or did not use any	The physician is unfamiliar with mandatory tools like telephones, checklists and contact information
Employee did not know where to find the contact information for the consultant
Instructions for using preoperational checklist were not clear or known and the checklist was not used
The patient from the ED going to the operating room did not have the appropriate surgical preparation checklist like marking the operative side, urinary catheter, and blood order.
The patient did not receive medicines and blood tests because the orders were not carried out correctly	The new electronic system had been implemented in the ED, but there was no introduction or training of using it
Referral did not reach the correct follow-up treatment department
When treating a critical patient, roles and responsibilities were not clear between different medical specialities	Multiprofessional cooperation principles are not familiar to all physicians
Physicians of different medical specialities did not know their responsibilities
Consultant ordered the patient to have an operation but did not inform the nurse in charge
Discharged dementia patients’ report did not reach follow-up care (see prob 5)	Insufficient knowledge in the ED about reporting principles and processes for patients with special needs
Treatment of threatening alcohol delirium was referred to a psychiatric nurse and medication was not implemented properly in time
Too many tasks for nurses caused delay of treating elderly patient.	Shortage of nurses/ nursing personnel: No basic nursing staff for taking care of basic hygiene like diaper change and medication delays when nurses doing it	A. Medical staff orientation, onboarding and competence requirements B. Human resources on duty D. Medication documentation system E. Interprofessional collaboration and teamwork	2. Insufficient human resources available
The patient was lying in his feces and urine for five hours, which damaged the skin.
Because of treatment delay, the patient became delirious and was medicated with a sedative.
No diaper change for an elderly patient visiting the ED for a day
Shortage of nursing staff caused delay in starting important intravenous antibiotics.
The patient did not have a cannula and antibiotics were given a few hours later in the ward after discharge from the ED
The ED physician had no possibility to leave the ED and help on the ward, or the treatment of the patients in the ED would have delayed.	Shortage of physicians
Need for an on-call physician to come to the ward because there was a patient in a severe condition, but it was impossible to leave the ED
Acute need to look for contact information of a discharged patient, but there was no time to do it	Shortage of helping personnel: No staff to update and organize important instructions and the list of telephone numbers
The physician tried to call these numbers, but they said they were not in use. Contact information was not updated.
Physician could not open the ECG in the ED, because of the machine was broken, Insufficient equipment like a broken ECG device and no staff to take care of it.
There was no time to find out if the elderly person needed help at home
Could not find important information about the patient easily and there was no time for nurse to keep searching
Many inexperienced physicians at the same time who were slow and who needed to consult very much and could not help on the ward	Inexperienced physician and no consult
Very inexperienced physician gave inadequate treatment and instructions
No time for young physician to familiarize with the instructions. Orders were inadequate.
The medication list was incorrect or old, and it had not been checked in the ED	Lack of medication information managing personnel and poor medication documentation system
Challenge to find adequate medication from differing medication documentation systems and lack of time to do it. No personnel to do it.
Nurse could not recognize the critical patients during triage	A discrepancy between the level of requirements of triage nurse and competence of doing it.	A. Medical staff orientation, onboarding and competence requirements B. Human resources on duty E. Interprofessional collaboration and teamwork F. Professional resources for specific patient groupsa	3. Deficient professional skills
The patient with a wound that needed stitches was sent home without seeing a physician
Triage took the patient in the ED even if there was no need for treatment in the ED
Young patient with symptoms of sepsis triaged to GP
COPD patient´s dyspnea and CO2 retention were treated improperly in the ED and the patient did not get proper treatment until on the ward	A discrepancy between the level of requirements of the ED physician and competence of doing it.
Physician could not recognize a critical immunosuppressed patient
The physician did not recognize the signs of serious operative condition and transferred the patient to the ward too early.
The physician did not recognize psychiatric emergency and discharged the patient without psychiatric consultation
The physician did not read documentation of paramedics and missed critical information.	Poor skills of multiprofessional collaboration
Critical information about the psychiatric patient was not given when reporting the patient
The physician did not ensure that follow-up instructions were clear to the patient.	Poor skills of communication
Dementia patients were discharged from the ED without confirmation that they could manage alone.	Lack of knowledge about the special needs of the geriatric patient and the discharge process of dementia patients
Dementia patient´s discharged from the ED without informing home nurse or family
A dementia patient who had fever and who was totally dependent on other people´s care was sent home from the ED by taxi without shoes or informing family or home care. It was wintertime.
Nurse made a cast and forgot the ECG electrode inside	Lack of training special skills of plastering.
Medication list was incorrect when the patient discharged from the ED to the ward or home.	Lack of knowledge about importance about current medication documentation and no protocol for it	A. Medical staff orientation, onboarding and competence requirements B. Human resources on duty C. Electronic medical records and information transfer D. Medication documentation system. E. Interprofessional collaboration and teamwork F. Professional resources for specific patient groupsa	4. Medication Management Deficiencies
Incomplete prescription or medication order
The patient started taking wrong medication after discharge from the ED because of outdated medication list.
Medication was not up-to-date when treating a current illness and the patient was at risk of obtaining harmful drugs
The patient was not able to remember new mediation because of dementia, and no documentation of medication changes was given from the ED.
Nurse or physician could not reconcile medication because of different medical documentation systems	Different medical documentation systems between treating facilities
Medication prescribed from GP was not given to the patient in the ED, because of separate documentation systems
Not possible to find out the current medication, because of different electronic medical records and medical documentation systems between treatment facilities and lack of time
No time to do proper Medication Reconciliation for nurse or physician	Lack of time
Not possible to find out the current medication fast enough
No Hospital Discharge Checklist or not using it	Process problems in discharging
The receiving care facility did not get proper instructions about the patient’s treatment	Lack of knowledge about the importance of information transfer to follow-up care or the process for doing it	A. Medical staff orientation, onboarding and competence requirements C. Electronic medical records and information transfer D. Medication documentation system. E. Interprofessional collaboration and teamwork F. Professional resources for specific patient groupsa	5. Incomplete information transfer from ED
Patient’s vital signs were poor already while transferring, but information on the situation was not given in the report
No written or oral reporting to the follow-up treatment facilities
The patient is transferred from the ED to ward with symptoms of gastroenteritis without informing ward and without isolation
The patient had infectious disease, but the information did not reach the ward when transferring
The physician did not ensure that dementia patient understands the instructions and did not document them	Lack of time and personnel to ensure that information about a discharging dementia patient and follow-up treatment instructions are given to caretakers
Information about dementia patient´s discharging, and follow-up treatment instructions did not reach the home nursing service
Dementia patient was sent back to nursing home without any document about visit in the ED or telephone report
Referral for further examinations was missing	Inappropriate tools for data transfer between organizations
The patient documents and laboratory results taken in the ED were not seen in GP
We did not see central hospital records anywhere. No paper came with the patient.
Relevant information did not receive psychiatric patient, because of separate documentation systems
The physician did not give the instructions to patient and did not document them in the system	Lack of knowledge about the importance of patient information
Unclear follow-up instructions to the patient after discharging the ED
Physician in the evening shift examined only Swedish-speaking patients	No language requirement for professionals	A. Medical staff orientation, onboarding and competence requirements B. Human resources on duty	6. Language proficiency
Information available only in one language and professional did not understand it
Treatment delayed because only patients with same language as the physician were treated during the night
There was no time for proper use of interpreting service	Lack of time or problems using interpreting tools
Time shortage when treating patients in need of interpreting services
Professional did not know how to use interpreting telephone
Senior consultant refused to come to the ward when asked	Lack of physician resources for help on wards during on-call shifts.	A. Medical staff orientation, onboarding and competence requirements B. Human resources on duty E. Interprofessional collaboration and teamwork F. Professional resources for specific patient groupsa	7. Unprofessional behavior
Disrespectful speech towards mental health patients	Prejudgment of psychiatric patients
The ED personnel talked unprofessionally about the skills of the psychiatry staff when patient was present	Poor skills of multiprofessional collaboration and respect for other professionals
Behavior problems or disrespect towards nurses on the ward
Patient urgently transferred to operation unit and wrong patient information was attached	Urgent situation	A. Medical staff orientation, onboarding and competence requirements E. Interprofessional collaboration and teamwork	8. Identification error
The patient had an invalid social security number on the ID wristband.	No protocol for identification in Triage or not employing it properly
Patient did not have ID wristband at all
Patient´s contact information had not been asked in triage
Medication order to the wrong patient
Aggressive patient or threat of violence	Lack of knowledge about treating special patient groupsa	A. Medical staff orientation, onboarding and competence requirements B. Human resources on duty F. Professional resources for specific patient groupsa	9. Patient-dependent problem
Treatment of a patient with challenging behavior like delirium	Shortage of staff and time to react to unexpected situations.
Aggressive psychiatric patient needed two nurses and other patients’ treatment delays
Suicidal action
Aggressive suicidal patient and no permission to sign referral to compulsory treatment	Deficiencies as regards physician´s legal rights	A. Medical staff orientation, onboarding and competence requirements B. Human resources on duty	10. Other
Treatment delayed because of a change of shift	Deficiencies in shift scheduling
Interruption of information flow caused by shift change

^aGeriatric, mental health and substance abuse disorder patients