Definitions and examples of contributing causes
| Systems issues |
| Definition: The health system structure, organisation, processes or equipment contributed to the event, such as lack of availability of clinical information, poor transitions in care settings, lack of self-management support or system resources. |
| Examples |
| Medication availability: physicians are unaware of formulary changes because they are not updated in the electronic prescribing system. |
| Diagnostic results: test results sent only to ordering clinicians, not to primary care providers |
| Impaired patient–clinician communication |
| Definition: Inadequate exchange of relevant information contributed to the event, such as language barrier, failure to convey/elicit symptoms or lack of patient understanding. |
| Examples |
| Health literacy: patient was unable to read prescription label; taking acetaminophen instead of metformin. |
| Physician unaware: patient has significant gastrointestinal distress leading to non-adherence with metformin, unknown to physician* |
| Patient contribution |
| Definition: A patient action or inaction, not related to clinician communication, contributed to event, such as harmful health beliefs, treatment non-adherence and financial barriers. |
| Examples |
| Health belief: patient refuses to initiate insulin despite worsening diabetes control because he believes it is responsible for his relative's amputation. |
| Insurance lapse: patient cannot pay for medications; his Medicaid lapsed when he failed to complete needed paperwork. |
| Clinician contribution |
| Definition: A clinician action or inaction, not related to clinician communication, contributed to event, such as errors in diagnosis and treatment, inadequate monitoring or failure to review relevant information. |
| Examples |
| Dosage error: physician prescribes twice the maximum daily dose of pioglitazone. |
| Inadequate monitoring: physician does not order serum creatinine and potassium following initiation of an ACE inhibitor. |
↵* The medical record did not allow coders to determine whether the clinician failed to elicit symptoms or the patient failed to report them.