Table A1 All actions generated (n = 657) for single case adverse drug event root cause analyses

Action	Number	Per cent of total	Per cent of category	Action	Number	Per cent of total	Per cent of category
Clinical changes at the bedside	172	26.18	100	Equipment/computer-related actions	73	11.11	100
Unspecified clinical changes	60	9.13	34.8	Electronic template or tool	24	3.65	32.9
Drug storage	25	3.81	14.5	Unspecified equipment related actions	18	2.74	24.7
Drug dispensing	24	3.65	14.0	Explore improving/obtaining software/	12	1.83	16.4
Explore possibility of changes to the	22	3.35	12.8	hardware
clinical process				Install/improve software alerts	7	1.07	9.6
Changing order entry through alerts,	12	1.83	7.0	Hardware acquisition	4	0.61	5.5
forcing functions				Plan to improve/obtain new software/	4	0.61	5.5
Encouraging people to use existing	10	1.52	5.8	hardware
computer capacity				Update software	3	0.46	4.1
Inpatient pharmacy medication verification	7	1.07	4.1	Improve software interface	1	0.15	1.4
Action related to outpatient	4	0.61	2.3
medication delivery				Communication actions	38	5.78	100
Action related to medication scans	4	0.61	2.3	Unspecified communication actions	25	3.81	65.8
Outpatient verification of medication	3	0.46	1.7	Improve communication with pharmacy	7	1.07	18.4
Action related to wristband scans	1	0.15	0.6	Improve reporting of equipment/	3	0.46	7.9
				software failures
Policies and procedures	163	24.81	100	Standardise terminology	2	0.30	5.3
Unspecified changes in policy or procedure	58	8.83	35.6	Improve reporting of events/close calls	1	0.15	2.6
Medication administration	35	5.33	21.5
Medication dispensing	23	3.50	14.1	Data collection/use	22	3.35	100
Adherence to medication administration	20	3.04	12.3	Assess/analyse data for process for	11	1.67	50.1
policy				improvement
Adherence to medication dispensing policy	11	1.67	6.8	Unspecified data collection/use	6	0.91	27.3
Doctor prescribing/ordering	9	1.37	5.5	Improve data collection process	5	0.76	22.8
Adherence to doctor prescribing/ordering	5	0.76	3.1
policy				Obtain more information/explore options	21	3.20	100
Improve medication finishing	2	0.30	1.2
				Actions not otherwise specified	25	3.81	100
Training and education actions	143	21.77	100
Development/implementation of a cognitive	34	5.18	23.8
aid/reminder
Unspecified training or education	32	4.87	22.4
Medication administration	24	3.65	16.8
New policy or procedure	23	3.50	16.1
Order finishing and dispensing procedure	13	1.98	9.1
Use of equipment	8	1.22	5.6
Order entry	5	0.76	3.5
Use of alerts	2	0.30	1.4
Supervisor training	2	0.30	1.4