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Table 3 Examples of contributing factors by the dimensions and sub-dimensions of CADYA

From: Factors contributing to patient safety incidents in primary care: a descriptive analysis of patient safety incidents in a French study using CADYA (categorization of errors in primary care)

Item

Examples of patient safety incidents (in the ESPRIT study)

ENVIRONMENTAL FACTORS

Patient’s social context

Elderly, suffering from dementia, unsuitable assistance plan

Background of care

 Unplanned consultation

A woman took an appointment just for herself and came with her son

 Place of care

Incomplete medical examination because the patient was seen at home

 Workload management

Workload increased by adding too many consultations

 Disruptive element

Phone call caused the physician to dismiss his patient

Health system

 Healthcare service

A medical specialist was required but unavailable on weekends

 Financial or administrative issue

No general practitioner declared to social security

HUMAN FACTORS

 Linked to the patient

Aggressive patient (who felt rejected by her physician)

 Linked to the provider

Stressed physician (bad news needed to be announced)

 Linked to other providers

Pharmacist distracted when dispensing treatment

 Linked to a third party

Indiscretion of the mother of a patient regarding her daughter

TECHNICAL FACTORS

Equipment

 Failure, malfunction, unavailability

Failure of the computer server

 Incorrect use

Wound following the inappropriate use of pedicure equipment

Information system

 Incorrect or missing data

Lack of discharge letter after hospitalization of a patient

 Failure of the communication system

Ultrasound result was unreadable over the internet

PROCESS OF CARE

Cognitive dimension

 Lack of initial training

Ignorance of drug contraindication

 Incorrect recall (after training)

Insufficient exploration of thromboembolic risk

 Wrong synthesis

Minimization of a chronic kidney disease

Care procedure

 Inappropriate or unachieved procedure

Coronary patient who stopped the statin on her own

 Lack of protocol

Medical appointment for an emergency assigned too late by the secretary

Care coordination

 Communication failure

The nurse did not call the physician despite an unusual dosage

 Lack of (or incorrect) monitoring

Lack of specialized ophthalmic monitoring despite serious uveitis

 Lack of response after feedback

Diabetes mellitus non-equilibrated, without medical appointment, for several months despite several blood tests