Example events and coding scheme
| Case 1. A 69-year-old man with diabetes has had worsening diabetes control. His primary care physician doubles the dose of his current metformin, adds glyburide and pioglitazone, and schedules follow-up in 4 months. When he begins the telephone self-management support intervention 2 months later, he requests a call-back from the study nurse. He reports that since his last visit, he has had frequent episodes of feeling sweaty and shaky, with blood sugar of 50s, two to three times per week. He had not informed anyone of these symptoms and did not know that they were related to his diabetes medicines. | |
| Coding element | Rationale |
| Event type: Adverse event | Harm to patient (symptoms) |
| Self-management domain: medication use | Directly related to medication escalation |
| Contributing cause: clinician | Aggressive medication intensification without follow-up visit or other monitoring before 4 months |
| Contributing cause: communication | Patient unaware of the relationship between higher doses of diabetes medications and his symptoms |
| Contributing cause: patient | Patient did not convey symptoms to a clinician |
| Harm | Symptoms, >1 day |
| Case 2. A 57-year-old woman responses to the automated call triggered a call-back from the nurse care regarding diabetes diet. During the live call, she described some uncertainty about her medications. She was recently hospitalised for an exacerbation of congestive heart failure and renal insufficiency, and received new prescriptions upon discharge. When she returned home, she had a bottle of benazapril 20 mg tablets from before her admission and a new bottle of benazapril 40 mg tablets prescribed by the hospital physicians. She had been taking both, on the assumption that her hospital physicians were adding them to her prior regimen. | |
| Coding element | Rationale |
| Event type: potential adverse event | No documented harm, but risk from unintended high dose of medication |
| Self-management domain: medication use | Directly related to medication change in different care setting |
| Contributing cause: communication | Patient did not comprehend medication instructions |
| Contributing cause: systems | Lack of a standardised postdischarge medication reconciliation process |
| Harm | None |