Table 3

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 elementRationale
Event type: Adverse eventHarm to patient (symptoms)
Self-management domain: medication useDirectly related to medication escalation
Contributing cause: clinicianAggressive medication intensification without follow-up visit or other monitoring before 4 months
Contributing cause: communicationPatient unaware of the relationship between higher doses of diabetes medications and his symptoms
Contributing cause: patientPatient did not convey symptoms to a clinician
HarmSymptoms, >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 elementRationale
Event type: potential adverse eventNo documented harm, but risk from unintended high dose of medication
Self-management domain: medication useDirectly related to medication change in different care setting
Contributing cause: communicationPatient did not comprehend medication instructions
Contributing cause: systemsLack of a standardised postdischarge medication reconciliation process