Table 6

Distribution of contributory factors

Types of contributory factor: circumstances, actions or influences which are thought to have played a part in the origin or development, or to increase the risk, of a patient safety incident46 At least slight to modest evidence of avoidability, n (%)At least possible evidence of avoidability, n (%)At least probable evidence of avoidability, n (%)
Patient factors82(71.9)59(69.4)32(68.1)
 Multimorbidity: patient has two or more chronic medical conditions20(17.5)15(17.6)11(23.4)
 Comorbidity: the presence of one or more additional diseases8(7.0)5(5.9)3(6.4)
 Rare presentation: an uncommon pattern of signs or symptoms8(7.0)5(5.9)3(6.4)
 Previous medical/medication history8(7.0)5(5.9)3(6.4)
 Patient age7(6.1)6(7.1)3(6.4)
 Pathophysiological factors: the patient’s physical and medical well- being and health inclusive of frailty6(5.3)5(5.9)3(6.4)
 Clinician perception of patient behaviours: the way in which patients or caregivers act towards clinicians6(5.3)5(5.9)1(2.1)
 Response to medical advice: patient does not appear to follow the advice or instructions given by the clinician6(5.3)4(4.7)
 Complex agenda: patient presents with multiple issues in a single consultation4(3.5)3(3.5)1(2.1)
 Medication taking: patient does not appear to take medication as prescribed2(1.8)2(2.4)
 Clinical history taking: problems with eliciting relevant information2(1.8)1(1.2)1(2.1)
 Language: patient unable to communicate in English2(1.8)2(2.4)2(4.3)
 Disability: a physical or mental condition that limits a person’s movements, senses or activities2(1.8)1(1.2)1(2.1)
 Does not leave the house or home1(0.9)
Staff factors8(7.0)7(8.2)5(10.6)
 Inadequate knowledge/skill set6(5.3)6(7.1)4(8.5)
Organisational issues24(21.1)19(22.4)10(21.3)
 Continuity of care across system: problem with the delivery of a
 ’seamless service' through integration, coordination and sharing of information between different providers
 Continuity of care within primary care: seen by multiple members of the team within the same practice6(5.3)3(3.5)1(2.1)
 Continuity of care between secondary and primary care: lack of coordinated care2(1.8)1(1.2)
 Protocols/policies/standards/guidelines inadequate, inefficient, absent or not available
 (specific problems noted below)
 Repeat prescribing1(0.9)1(1.2)1(2.1)
 Locum or agency staff1(0.9)1(1.2)1(2.1)
 Waiting lists for ‘urgent’ referrals1(0.9)1(1.2)1(2.1)
Total (%)114(100)85(100)47(100)