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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 causesn (%)
Deficiencies in nursing care, treatment, and diagnostics629 (47.9)
 Nursing care – delayed, erroneous, omitted, incomplete168 (26.7)
 Treatment – delayed, erroneous, omitted, incomplete143 (22.7)
 Observation – delayed, erroneous, omitted, incomplete100 (15.9)
 Follow-up of care/treatment – delayed, erroneous, omitted, incomplete91 (14.5)
 Performance of task – deficient58 (9.2)
 Diagnostics/examination – delayed, erroneous, omitted, incomplete43 (6.8)
 Paramedical care – delayed, erroneous, omitted, incomplete17 (2.7)
 Acting outside own area of competence4 (0.6)
 Checking/labelling of samples, examination, patient identity – deficient3 (0.5)
 Preparation of patient ahead of operation, examination – inadequate2 (0.3)
Deficiencies in communication, information, and collaboration257 (19.5)
 Communication/information – deficiencies between different care providers54 (21.0)
 Collaboration/continuity/care planning – deficiencies within the unit48 (18.7)
 Communication/information – deficiencies within own unit/care provider44 (17.1)
 Communication/information – deficiencies in relation to patient/next-of-kin36 (14.0)
 Collaboration/continuity/care planning – deficiencies between units24 (9.3)
 Information – deficiencies in acting on available information22 (8.6)
 Interpretation of information – deficiencies10 (3.9)
 Attention and/or having expected staff not visit – deficiencies, delays9 (3.5)
 Discharge planning – deficiencies6 (2.3)
 Communication/information – deficiencies regarding decision-making conversations3 (1.2)
 Language barriers1 (0.4)
Deficiencies in the organization204 (15.5)
 Routines/guidelines – lacking, deficient, have not been observed81 (39.7)
 Routines/guidelines – unknown24 (11.8)
 Deficiencies in competence and experience23 (11.3)
 General organizational flaws20 (9.8)
 Deficient relational continuity13 (6.4)
 Resources – lacking12 (5.9)
 Distribution of responsibilities – unclear12 (5.9)
 Wrong level of care9 (4.4)
 Management – deficiencies7 (3.4)
 Availability – lacking3 (1.5)
 Physician with patient responsibility not appointed1 (0.5)
Deficiencies in medication management process168 (12.8)
 Medication – prescription – delayed, erroneous, omitted, incomplete62 (36.9)
 Medication – distribution – delayed, erroneous, omitted, incomplete58 (34.5)
 Medication – preparation – delayed, erroneous, omitted, incomplete29 (17.3)
 Medication – lacking in-depth presentation of drug14 (8.3)
 Medication – side effects5 (3.0)
Technical device issues19 (1.4)
 Medical equipment, tool – handling errors, lacking knowledge on use12 (63.2)
 Medical equipment, tool – insufficient access, defects, insufficient maintenance6 (31.6)
 IT-related – problem with IT system, insufficient access, handling errors1 (5.3)
Other37 (2.8)
 Not apparent from record33 (89.2)
 Other cause4 (10.8)
Total1314 (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