Table 2

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.
  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.
  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.
  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.
  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.