Table 4

Top 10 causal factors and associated root causes of included pADEs

Causal factor due to associated root causeExample of type of pADE% of all root causes% of patients impacted by root cause
Patient had not understood information (possibly) previously provided due to provider not confirming patient understandingMany different pADEs (except antibiotic related)35/281 (12.4)35/120 (29.2)
Unable to recognise medication side effect due to providers not confirming ability to do thisBleeding, orthostatic hypotension, constipation28/281 (10.0)28/120 (23.3)
Prescribing (and not identified or managed at dispensing) antibiotics for CAP 25% of pADEs due to lack of referral to guidelineUnresolved pneumonia24/281 (8.5)24/120 (20)
Intentional non-adherence due to mainly not understanding purpose/benefit of medication┬▒having concerns about taking it; provider not confirming that patient understands benefits/not identifying or addressing concernStroke, MI, aortic dissection, COPD, asthma, heart failure exacerbations20/281 (7.1)20/120 (16.7)
Medication monitoring provider (no actionable root cause identified: lack of system reminder, healthcare provider lapse, community pharmacy not routinely asking patient about bloodwork, except for lack of reminder on laboratory report to calculate phenytoin for low albumin n,1)Acute kidney injury, hypothyroidism, phenytoin toxicity (n,1)18/281 (6.4)18/120 (15.0)
Could not identify if medication was working due to provider not confirming that patient can identify how medication is working and providing specific parameters (daily weighing, measuring BP)Heart failure exacerbations, intracranial haemorrhage, hypertensive urgency17/281 (6.0)17/120 (14.1)
Patient did not have a sick day medication plan; due to lack of locally available resource in use, incorporation into routine practice; recognition of this as root cause in affected pADEsHypotension, acute kidney injury, elevated INR, bleeding, hypoglycaemia15/281 (5.3)15/120 (12.5)
Lack of provision of action plans for COPD, asthma or heart failureCOPD, asthma, heart failure13/281 (4.6)13/120 (10.8)
Provider not assessing medication use competency (ability to safely and reliably take medications)Bleeding, drug toxicity, stroke12/281 (4.3)12/120 (10)
Provider had not adjusted medication based on laboratory parameters (actionable root cause not identified, presumed lapse by providers, laboratory results not available to community pharmacists)Acute kidney injury, bleeding, stroke (due to hyperthyroidism)11/281 (3.9)11/120 (9.2)
Provider not assessing medication monitoring competency (ability to monitor for side effects or lack of effectiveness)Bleeding, weakness, hypotension, heart failure, myxoedema11/281 (3.9)11/120 (9.2)
  • BP, blood pressure; CAP, community-acquired pneumonia; COPD, chronic obstructive pulmonary disease; INR, international normalised ratio; MI, myocardial infarction; pADE, preventable adverse drug event.