Errors and adverse events in family medicine: Developing and validating a Canadian taxonomy of errors

Sarah Jacobs; Maeve O’Beirne; Luz Palacios Derfiingher; Lucie Vlach; Walter Rosser; Neil Drummond

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Table 1

Types of errors

TYPE OF ERROR	DEFINITION
Administrative	Events relating to office work, such as filing, billing, and booking appointments (eg, office secretaries are unable to locate a patient’s chart at the time of an appointment, resulting in delays for the patient)
Communication	Events relating to transfer of information (eg, the administration changed the after-hours coverage system, leaving nurses confused regarding who is on call and creating difficulties in finding an appropriate physician)
Diagnostic	Events relating to the process of diagnosing a patient, including incorrect diagnoses and delays caused by waiting for diagnostic services, such as laboratory tests and diagnostic imaging (eg, failing to diagnose a breech presentation in a pregnant patient)
Documentation	Events involving written documents, such as notes, charts, and letters, that contain incorrect information, or in which the wording or presentation of information makes accurate interpretation difficult (eg, an immunization recorded on the wrong chart because another patient has the same last name)
Medication	Events relating to medications, including allergic reactions, prescribing errors (wrong drug or wrong dose), and drug side effects (eg, a formulation of acetaminophen and codeine is prescribed to a palliative care patient who is allergic to acetaminophen)
Surgical or procedural	Events involving medical or surgical treatments or interventions, but excluding those involving medications (eg, a belt and clamp mechanism slipped, resulting in loss of hemostasis and poor excision)

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Table 2

Types of causal factors

CAUSAL FACTOR	DEFINITION
Case complexity	Patient has numerous medical conditions or complaints during a single consultation or patient’s medical conditions are highly complex or masked by unusual presentations (eg, forgot to administer vitamin B₁₂ injection because of complex health problems and schizophrenia)
Discontinuity of care	Logistic break in delivery of care, such as between departments, clinics, and doctors. Also includes cases in which insufficient information was transferred about a patient between places, agencies, or individuals, or between the conduct of discrete procedures (eg, a child was referred to emergency for intussusceptions, but the emergency physician erroneously diagnosed the child as having a viral gastrointestinal infection and did not call the referring physician, although he wrote a detailed note)
Failure to follow protocol or accepted practice	Knowing appropriate procedures, but failing to conform to them. Lack of attention to procedure or diagnosis, but without time or work pressure (eg, important prescription for antibiotics not filled by nursing home for 3 days because administrators did not understand the clinical need)
Fatigue	Physicians’ fatigue impairs ability to think clearly or use appropriate procedures (eg, forgot to explain treatment procedure in emergency room late at night due to tiredness)
Gap in knowledge	Unable to choose correct course of action because of insufficient knowledge, either received or experiential (eg, patient with a history of Parkinson disease and an overactive bladder is taking selegiline for the Parkinson disease. Physician prescribed oxybutynin for overactive bladder; pharmacist called to advise that oxybutynin not recommended for patients with Parkinson disease)
High workload	Insufficient time to attend to clinical or administrative task properly (eg, wrong label was placed on a laboratory requisition)
Insufficient information on pharmacologic properties of medication	Medications incorrectly prescribed or administered because they are not sufficiently documented in the literature, or because, despite effort, a physician was unable to find sufficient information on the medication (eg, prescribed codeine syrup 15 mg/5 mL, but pharmacy only carried it in 25 mg/5 mL strength, and there was no information in the formulary on standard strength)
Medication side effects	Directly related to the composition of a pharmaceutical and its possible effect on patients, such as when patients develop known side effects or have undiagnosed allergies (eg, patient prescribed naproxen for lower wrist tendonitis complained of nausea, gastrointestinal upset, and diarrhea)
Relationship dynamics	Nature of the relationship between a health care professional and patient precipitates an error or event (eg, prescribed nonsteroidal anti-inflammatory drug to a patient with heart disease because of pressure from the patient)
Structural problems	Flaws in technical or organizational infrastructure or poor environmental design. Could relate to operational protocols, organizational structures, software, or poor machinery or computer systems (eg, laboratory results page formatted so that computer cuts off values)

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Table 3

Inter-rater reliability for types of errors or adverse events and causal factors

TYPE OF ERROR OR ADVERSE EVENT AND CAUSAL FACTOR	KAPPA VALUE	MCNEMAR^*
TYPE OF ERROR
Administrative	0.77	1.00
Communication	0.61	0.69
Diagnostic	0.65	1.00
Documentation	0.76	1.00
Medication	0.83	1.00
Surgical or procedural	0.73	0.50
TYPE OF CAUSAL FACTOR
Case complexity	0.79	1.00
Discontinuity of care	0.70	0.25
Failure to follow protocol or accepted practice	0.17	0.23
Fatigue	1.00	1.00
Gap in knowledge	0.21	0.22
High workload	0.94	1.00
Insufficient information on pharmacologic properties of medication	0.65	0.50
Medication side effects	1.00	1.00
Relationship dynamics	0.50	1.00
Structural problems	0.73	1.00