From: Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology
Type of contributing causes | n (%) |
---|---|
Deficiencies in nursing care, treatment, and diagnostics | 629 (47.9) |
Nursing care – delayed, erroneous, omitted, incomplete | 168 (26.7) |
Treatment – delayed, erroneous, omitted, incomplete | 143 (22.7) |
Observation – delayed, erroneous, omitted, incomplete | 100 (15.9) |
Follow-up of care/treatment – delayed, erroneous, omitted, incomplete | 91 (14.5) |
Performance of task – deficient | 58 (9.2) |
Diagnostics/examination – delayed, erroneous, omitted, incomplete | 43 (6.8) |
Paramedical care – delayed, erroneous, omitted, incomplete | 17 (2.7) |
Acting outside own area of competence | 4 (0.6) |
Checking/labelling of samples, examination, patient identity – deficient | 3 (0.5) |
Preparation of patient ahead of operation, examination – inadequate | 2 (0.3) |
Deficiencies in communication, information, and collaboration | 257 (19.5) |
Communication/information – deficiencies between different care providers | 54 (21.0) |
Collaboration/continuity/care planning – deficiencies within the unit | 48 (18.7) |
Communication/information – deficiencies within own unit/care provider | 44 (17.1) |
Communication/information – deficiencies in relation to patient/next-of-kin | 36 (14.0) |
Collaboration/continuity/care planning – deficiencies between units | 24 (9.3) |
Information – deficiencies in acting on available information | 22 (8.6) |
Interpretation of information – deficiencies | 10 (3.9) |
Attention and/or having expected staff not visit – deficiencies, delays | 9 (3.5) |
Discharge planning – deficiencies | 6 (2.3) |
Communication/information – deficiencies regarding decision-making conversations | 3 (1.2) |
Language barriers | 1 (0.4) |
Deficiencies in the organization | 204 (15.5) |
Routines/guidelines – lacking, deficient, have not been observed | 81 (39.7) |
Routines/guidelines – unknown | 24 (11.8) |
Deficiencies in competence and experience | 23 (11.3) |
General organizational flaws | 20 (9.8) |
Deficient relational continuity | 13 (6.4) |
Resources – lacking | 12 (5.9) |
Distribution of responsibilities – unclear | 12 (5.9) |
Wrong level of care | 9 (4.4) |
Management – deficiencies | 7 (3.4) |
Availability – lacking | 3 (1.5) |
Physician with patient responsibility not appointed | 1 (0.5) |
Deficiencies in medication management process | 168 (12.8) |
Medication – prescription – delayed, erroneous, omitted, incomplete | 62 (36.9) |
Medication – distribution – delayed, erroneous, omitted, incomplete | 58 (34.5) |
Medication – preparation – delayed, erroneous, omitted, incomplete | 29 (17.3) |
Medication – lacking in-depth presentation of drug | 14 (8.3) |
Medication – side effects | 5 (3.0) |
Technical device issues | 19 (1.4) |
Medical equipment, tool – handling errors, lacking knowledge on use | 12 (63.2) |
Medical equipment, tool – insufficient access, defects, insufficient maintenance | 6 (31.6) |
IT-related – problem with IT system, insufficient access, handling errors | 1 (5.3) |
Other | 37 (2.8) |
Not apparent from record | 33 (89.2) |
Other cause | 4 (10.8) |
Total | 1314 (100) |