Table 4

Categories of contributing factors for preventable and potential adverse events identified through prospective clinical surveillance

Preventable and potential adverse events (N=56)Total events* (n=94)Illustrative example
Contributing factor
 Number of contributing factors, median (IQR)3 (2–4)N/AN/A
 Number of events with only 1 contributing factor, n (%)6 (11%)N/AN/A
Organizational factors, n (%)
 Nutrition services10 (18)10 (11)Patient who is NPO received a meal tray
 Lab services3 (5)9 (10)Blood sample not processed due to form not being completed properly
 Administrative procedures (scheduling, availability of services)5 (9)7 (7)Non-medical patient bedspaced on medical ward due to lack of available beds
 Diagnostic imaging services3 (5)4 (4)Delay in obtaining a chest X-ray to confirm placement of a nasogastric tube
 Infection prevention and control3 (5)4 (4)Room not cleaned as per infection prevention and control procedure
 Ancillary services (housekeeping, transport)2 (4)2(2)A patient room was not adequately cleaned resulting in a hospital-acquired infection
 Blood bank/transfusion services0 (0)1 (1)No cross and type performed prior to transfusion
Infrastructural factors, n (%)
 Physical plant3 (5)4 (4)Shared patient room resulted in unnecessary patient exposure to MRSA
 Medical record functionality2 (4)2 (2)Auto-population of diet order from prior admission in the electronic patient record causes patient to receive incorrect diet
 New technology1 (2)2 (2)Remote monitoring of telemetry patients resulted in delayed response
 Equipment/supplies0 (0)1 (1)Incorrect suction catheter used for patient with tracheostomy
Policy and procedural factors, n (%)
 Inadequate dissemination (awareness, interpretation)21 (38)27 (29)Patients screened at high risk for falls did not have appropriate fall prevention strategies implemented
 Poorly designed5 (9)5 (5)Policy surrounding assessments for rehabilitation require a second independent assessment, which delays patient recovery
 Conflicting policies2 (4)3 (3)The need to transfer patients to satisfy infection prevention and control requirements conflicts with the policy to avoid moving patients at risk for delirium
Medication factors, n (%)
 Ordering problems8 (14)10 (11)A resident failed to hold aspirin prior to a procedure, resulting in a delay
 Other (eg, clarity of prescription at discharge)3 (5)6 (6)A physician provided a patient with a prescription for a medication that is not available through the outpatient pharmacy
 Transcribing problems5 (9)5 (5)A nurse forgot to transcribe a medication discontinuation order into the medication administration record
 Administering problems1 (2)1 (1)A patient takes medications left at the bedside for another patient in the same room
Provider factors, n (%)
 Teamwork/communication23 (41)32 (34)Difficulty paging and obtaining a specialist opinion result in a delay in care
 Inadequate patient monitoring or failure to respond to clinical deterioration12 (21)18 (19)Failure to follow up on a supratherapeutic INR—patient continued to receive warfarin inappropriately
 Education/training (knowledge, skills)15 (27)16 (17)Front-line nurse did not flush the port prior to clamping
 Documentation (medical, nursing)5 (9)15 (16)For a cancelled medication order, the nurse documented ‘not administered’ rather than discontinuing medication outright on the medication administration record
 Clinical judgement8 (14)10 (11)Patient with worsening pulmonary oedema interpreted as being agitated by the resident and treated with haloperidol
 Workload8 (14)9 (10)Delay in assessing an unstable patient admitted to the ward because the on-call physician was busy managing another patient
 Unprofessional behaviour3 (5)3 (3)Despite receiving feedback regarding the use of proper drainage equipment for nephrostomy tubes, a nurse purposely continued to use the wrong equipment
Patient factors, n (%)
 Patient preference/non-compliance4 (7)4 (4)Patient chose to have contrast administered via nasogastric tube prior to X-ray confirmed placement because he did not want to delay the CT scan
 Uncooperative behaviour1 (2)2 (2)Patient flagged as high risk for falls and repeatedly told not to ambulate independently, but chose to leave the ward without supervision
  • *In addition to preventable and potential adverse events, total events also include errors or cases of substandard care, as well as seven non-preventable adverse events with unrelated errors.

  • INR, international normalised ratio; MRSA, methicillin-resistant Staphylococcus aureus; NPO, nil per os (nothing by mouth).