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Table 2 Potential contributing causes influencing no-harm incidents

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)

  1. The number of potential contributing causes is higher than the number of no-harm incidents because the reviewers were allowed to choose more than one alternative for each no-harm incident