Exhibit 2.

Contributory Factors Associated With Process Breakdowns In Root Cause Analysis Reports Of Delays In Outpatient Diagnosis, Treatment, Or Both, National Center For Patient Safety, 2005–12

Type of factor (number of reports)	Number of factors	Percent of factors
coordination of care (104)	339	33.5
Failure of team cognition (102)	316	31.2
Poor communication (111)	204	20.1
Patient-related behavior (43)	90	8.9
Administrative issues (48)	64	6.3

Source Authors' analysis of 111 root cause analysis reports from the Department of Veterans Affairs National Center for Patient Safety, 2005–12.

Note The categorization of contributory factors is explained more fully in the text.