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/A | N/A |
| Number of events with only 1 contributing factor, n (%) | 6 (11%) | N/A | N/A |
| Organizational factors, n (%) | |||
| Nutrition services | 10 (18) | 10 (11) | Patient who is NPO received a meal tray |
| Lab services | 3 (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 services | 3 (5) | 4 (4) | Delay in obtaining a chest X-ray to confirm placement of a nasogastric tube |
| Infection prevention and control | 3 (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 services | 0 (0) | 1 (1) | No cross and type performed prior to transfusion |
| Infrastructural factors, n (%) | |||
| Physical plant | 3 (5) | 4 (4) | Shared patient room resulted in unnecessary patient exposure to MRSA |
| Medical record functionality | 2 (4) | 2 (2) | Auto-population of diet order from prior admission in the electronic patient record causes patient to receive incorrect diet |
| New technology | 1 (2) | 2 (2) | Remote monitoring of telemetry patients resulted in delayed response |
| Equipment/supplies | 0 (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 designed | 5 (9) | 5 (5) | Policy surrounding assessments for rehabilitation require a second independent assessment, which delays patient recovery |
| Conflicting policies | 2 (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 problems | 8 (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 problems | 5 (9) | 5 (5) | A nurse forgot to transcribe a medication discontinuation order into the medication administration record |
| Administering problems | 1 (2) | 1 (1) | A patient takes medications left at the bedside for another patient in the same room |
| Provider factors, n (%) | |||
| Teamwork/communication | 23 (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 deterioration | 12 (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 judgement | 8 (14) | 10 (11) | Patient with worsening pulmonary oedema interpreted as being agitated by the resident and treated with haloperidol |
| Workload | 8 (14) | 9 (10) | Delay in assessing an unstable patient admitted to the ward because the on-call physician was busy managing another patient |
| Unprofessional behaviour | 3 (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-compliance | 4 (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 behaviour | 1 (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).