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 presentation | Causal factors and identified key root causes |
| COPD/asthma 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 |
| Bleeding, 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) |
| Hypotension 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 |
| Hyponatraemia 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.