Table 5.
Most frequently identified factors that contributed to the development of preventable events (N = 782)
| Contributing factors identified among 782 preventable ADEsa | n (%) | |
|---|---|---|
| Communication problem | Lack of communication between a healthcare provider and a patient | 58 (7.4) |
| Lack of communication between physicians | 18 (2.3) | |
| Lack of communication between nurses | 6 (0.8) | |
| Lack of communication between physician and pharmacist | 3 (0.4) | |
| Lack of communication between physician and a nurse | 3 (0.4) | |
| Lack of communication between pharmacists | 2 (0.3) | |
| Drug delivery/labelling/packaging/storage problem | Drug name, label or packaging problem | 1 (0.1) |
| Drug storage or delivery problem | 1 (0.1) | |
| EMS problem | Ambulance did not transport hypoglycaemic patient to hospital | 3 (0.4) |
| Error | Provider error in drug administration | 1 (0.1) |
| Inadequate monitoring | Delay in or inadequate clinical reassessment after medication change | 122 (15.6) |
| Insufficient laboratory monitoring | 120 (15.3) | |
| Too aggressive medical therapy for patient's condition/age | 36 (4.6) | |
| Mental health illness/social problem‐related | Non‐adherence associated with mental health illness | 53 (6.8) |
| Patient confusion/dementia | 16 (2.0) | |
| Substance misuse | 15 (1.9) | |
| Missing information | Critical information missing that could have prevented or mitigated the ADE | 31 (4.0) |
| Non‐adherence | Patient preference to not take medications | 49 (6.3) |
| Prior ADE leading to patient non‐adherence | 38 (4.9) | |
| Patient self‐titrating medications inappropriately | 30 (3.8) | |
| No compliance aid when required | 20 (2.6) | |
| Patient non‐adherence due to financial/lack of coverage | 18 (2.3) | |
| Regimen too complex (e.g., high number of daily doses) | 11 (1.4) | |
| Patient missed doses (forgetfulness/intoxication) | 10 (1.2) | |
| Patient error in administration | 7 (0.9) | |
| Patient hearing problem | 1 (0.1) | |
| Prior ADE | Missed/misdiagnosed previous ADE | 3 (0.4) |
| Provider‐level problem | Provided inadequate patient education or instructions | 186 (23.8) |
| Provider non‐adherence with current treatment guidelines | 101 (12.9) | |
| Lack of staff education | 43 (5.5) | |
| Medication prescribed inappropriately because patient insisted | 18 (2.3) | |
| Prescribed despite lack of clear indication for the culprit drug | 10 (1.2) | |
| Systems level problem | Environmental problem | 4 (0.5) |
| Lack of quality control or independent check systems | 4 (0.5) | |
| Unable to access care | Patient unable to access a prescription refill | 44 (5.6) |
| Patient unable to access GP for appointment | 15 (1.9) | |
| Patient unable to access specialist for appointment | 8 (1.0) | |
| Patient unable to access appropriate level of care | 4 (0.5) | |
| aThere were 87 preventable adverse drug events with no identified contributing factors | ||