Table 3

Type of pADE-related admissions, causal factors and associated root causes: presentations with more than five cases AND at least one root cause addressed by a learning message

Type of presentationCausal factors and identified key root causes
16 cases (13.3%)
Intentional non-adherence due to patient lack of understanding of how medication helps them; provider not confirming how medication helps patient; poor technique; lack of provider assessment; lack of action plan provision
15 cases (12.5%)
Concomitant NSAIDs due to providers not asking screening questions for NSAIDS; not confirming if patient can identify red flag symptoms; eligibility for PPI (lack of referral to guideline)
14 cases (11.7%)
Patient not recognising side effects; provider not ensuring that patient can confirm red flag symptoms or not asked to measure BP; lack of provision of sick day medication plan
Heart failure
12 cases (10%)
Lack of daily weighing; provider not confirming that patient understands fluid-weight concept; how medication helps patient; lack of action plan
6 cases (5%)
Lack of provision of sick day medication plan, prescribing; provider not confirmed that patient can identify side effect
Pneumonia/Clostridioides difficile colitis
6 cases (5%)
Suboptimal antibiotic choice for pneumonia not identified at dispensing due to lack of referral to a guideline; unclear indication (C. difficile colitis)
Various types of presentation
6 cases (5%)
Medication mix-ups due to lack of confirming patient/family understands medication changes and need to implement them
Acute kidney injury
6 cases (5%)
Lack of provision of sick day medication plan (2 cases); provider deferring to specialist clinic (lack of expected monitoring frequency of serum creatinine; unidentified action able root cause, other than possible lack of reminder system); lack of adjustment (lapse) in response to abnormal serum creatinine
  • BP, blood pressure; COPD, chronic obstructive pulmonary disease; NSAIDs, non-steroidal anti-inflammatory drugs; pADE, preventable adverse drug event; PPI, patient and public involvement.