Table 3.
Examples of contributing factors by the dimensions and sub-dimensions of CADYA
| Item | Examples of patient safety incidents (in the ESPRIT study) |
|---|---|
| ENVIRONMENTAL FACTORS | |
| Patient’s social context | Elderly, suffering from dementia, unsuitable assistance plan |
| Background of care | |
| Unplanned consultation | A woman took an appointment just for herself and came with her son |
| Place of care | Incomplete medical examination because the patient was seen at home |
| Workload management | Workload increased by adding too many consultations |
| Disruptive element | Phone call caused the physician to dismiss his patient |
| Health system | |
| Healthcare service | A medical specialist was required but unavailable on weekends |
| Financial or administrative issue | No general practitioner declared to social security |
| HUMAN FACTORS | |
| Linked to the patient | Aggressive patient (who felt rejected by her physician) |
| Linked to the provider | Stressed physician (bad news needed to be announced) |
| Linked to other providers | Pharmacist distracted when dispensing treatment |
| Linked to a third party | Indiscretion of the mother of a patient regarding her daughter |
| TECHNICAL FACTORS | |
| Equipment | |
| Failure, malfunction, unavailability | Failure of the computer server |
| Incorrect use | Wound following the inappropriate use of pedicure equipment |
| Information system | |
| Incorrect or missing data | Lack of discharge letter after hospitalization of a patient |
| Failure of the communication system | Ultrasound result was unreadable over the internet |
| PROCESS OF CARE | |
| Cognitive dimension | |
| Lack of initial training | Ignorance of drug contraindication |
| Incorrect recall (after training) | Insufficient exploration of thromboembolic risk |
| Wrong synthesis | Minimization of a chronic kidney disease |
| Care procedure | |
| Inappropriate or unachieved procedure | Coronary patient who stopped the statin on her own |
| Lack of protocol | Medical appointment for an emergency assigned too late by the secretary |
| Care coordination | |
| Communication failure | The nurse did not call the physician despite an unusual dosage |
| Lack of (or incorrect) monitoring | Lack of specialized ophthalmic monitoring despite serious uveitis |
| Lack of response after feedback | Diabetes mellitus non-equilibrated, without medical appointment, for several months despite several blood tests |