Table 4.

Overview of perceived causes of safety issues (across domains)

Domain	Top Themes	Support from Data Sources
		Clinician / Staff Interviews	Patient Focus Groups	Observation Data
Missed, delayed, or incorrect diagnoses	Lack of interoperability between health information systems*	●	●	●
	Perceptions that EHR “problem lists” included outdated / incorrect diagnoses	●		●
	Lack of time to collect and synthesize patient information	●
	Communication failures between providers and patients	●	●
Delays in treatment or preventive services	Extended wait times to see specialists, particularly in behavioral or mental health	●	●
	Lack of follow-through with recommended screenings and diagnostic procedures	●	●
	Lack of clear workflows to support health information technology (HIT)	●
Medication Safety Issues	Challenges associated with patients’ adherence to medications	●	●
	Difficulties in maintaining a complete and accurate medication list	●	●	●
	Shortcuts during the medication reconciliation process	●		●
Issues of communication and coordination of care	Lack of interoperability between health information systems*	●		●

^*Denotes a cross-cutting theme that was present in multiple domains