Table 2 Individual, team, and system contributing factor analysis by peer experts

Individual contributing factor

# of case (n = 13)

 Failure to perform test/intervention

11

 Deficient assessment

11

 Misinterpretation of a test

3

 Insufficient knowledge/skill

2

 Inappropriate/failure to transfer

2

 Premature discharge

1

 Inadequate monitoring or follow-up

1

 Failure to read medical records

1

 Facility administrative procedure, inadequate

1

 Clinical procedure, inadequate

1

 Professional misconduct

1

 Factors related to provider's health

1

 Poor decision-making regarding management

1

 Failure to refer

1

Team contributing factors

# of case (n = 13)

 Documentation issues

11

 Communication breakdown, patient

3

 Communication breakdown, physicians

1

System contributing factors

# of case (n = 2)

 Resource issues

2

 Protocol, policy and procedure issues

2