Exhibit 2.
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.