Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research

Patient Educ Couns. 2006 Sep;62(3):302-15. doi: 10.1016/j.pec.2006.02.007. Epub 2006 Jul 31.


Objective: Diagram patients' views of the causes of adverse drug events (ADEs) in ambulatory care, examine characteristics of causes reported by patients, and identify those that have been studied in the medical and social science literatures.

Methods: Twenty-two primary care patients were interviewed using a root cause analysis approach. Diagrams derived from interviews were consolidated and displayed online as a composite interactive causal diagram. Patient-reported causes were compared to evidence in the social science and medical literatures.

Results: Patients ascribed 164 causes to ADEs occurring through eight major pathways, including medication nonadherence, prescriber-patient miscommunication, patient medication error, failure to read medication label/insert, polypharmacy, patient characteristics, pharmacist-patient miscommunication, and self medication. Most frequently reported causes were intrapsychic and interpersonal in nature. Most patient-reported causes have been studied, however, several practical and motivational antecedents lack research.

Conclusion: Conducting root cause analysis with patients reveals multiple logically linked aspects of medication safety in community settings that merit further research and consideration in patient and prescriber education.

Practice implications: This causal diagram provides a broadly accessible planning tool for reducing ambulatory ADEs by showing a comprehensive picture of potential causes, identifying causal factors supported by evidence, and disclosing likely consequences of change efforts. Also, patient-centered medication safety strategies should address psychological and practical barriers patients face in their everyday lives.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Ambulatory Care / organization & administration
  • Ambulatory Care / psychology*
  • Arizona
  • Attitude to Health*
  • Audiovisual Aids*
  • Causality
  • Communication Barriers
  • Data Interpretation, Statistical
  • Drug Labeling
  • Female
  • Health Services Needs and Demand
  • Humans
  • Male
  • Medication Errors* / methods
  • Medication Errors* / prevention & control
  • Medication Errors* / psychology
  • Middle Aged
  • Online Systems
  • Patient Care Planning / organization & administration
  • Patient Education as Topic / organization & administration*
  • Patient-Centered Care / organization & administration
  • Pharmacists / psychology
  • Polypharmacy
  • Professional-Patient Relations
  • Self Medication / adverse effects
  • Self Medication / psychology
  • Surveys and Questionnaires