Patient Error: A Preliminary Taxonomy

Stephen Buetow; Liz Kiata; Tess Liew; Tim Kenealy; Susan Dovey; Glyn Elwyn

doi:10.1370/afm.941

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Table 1.

Number and Age Distribution of Participants in Nominal Groups

Group	No.	Female No.	Age <20 y No.	Age 20–54 y No.	Age ≥55 y No.
Patient groups
1. English as a second language	9	7	0	5	4
2. High health literacy	5	5	0	5	0
3. Independent elders	8	4	0	2	6
4. Informal carergivers	8	8	0	7	1
5. Men	9	0	0	5	4
6. Māori	8	8	1	5	2
7. Teenagers	8	5	8	0	0
8. Women	9	9	0	7	2
Total	64	46	9	36	19
Professional groups
9. Family physicians	5	1	0	4	1
10. Practice nurses	7	7	0	4	3
11. Pharmacists	7	2	0	4	3
Total	19	10	0	12	7

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Table 2.

Taxonomy of Patient Error

			Examples^a
Level 1	Level 2	Level 3	Type of Error	Participant Comment
^a Groups are numbered according to Table 1.
Action errors
1. Attendance errors	1.1 Underattendance	1.1.1 Nonattendance	Refusal of visits	“If it runs through the family we seek no help” (group 2)
		1.1.2 Insufficient attendance	Less frequent attendance than recommended	“(Not) following your gut instinct and not seeking a second opinion” (group 8)
	1.2 Untimely attendance	1.2.1 Early attendance	Attendance for self-limiting conditions	“Hypochondriacal behavior” (group 5)
		1.2.2 Late attendance	Deferral of visit	“Delay in visiting the doctor when you know you’re sick” (group 2)
	1.3 Overattendance	1.3.1 Frequent attendance	More frequent attendance than required	“Overattendance (eg, because the doctor is cute)” (group 2)
	1.4 Misattendance	1.4.1 Inappropriate type of visit	Demand for a home visit by a patient who could have safely come to the clinic	Irregularity (group 2)
		1.4.2 No usual provider chosen	Frequently changing providers	“Consulting multiple doctors” (group 9)
		1.4.3 Use of unqualified sources	Use of unqualified complementary sources	Taking advice from marginal sources: “over the fence, nonqualified practitioners, TV adverts” (group 9)
		1.4.4. Refusals during visits	Refusal to be examined by a student doctor	“Refusing to be checked by the doctor” (group 1)
		1.4.5 No escort when needed	No interpreter	“Not coming in with an interpreter (friend/relative) when their communication in English is suboptimal” (group 9)
		1.4.6 Inappropriate escort/chaperone	Child	“Not telling doctor what their real concerns are” (group 9)
2. Assertion errors	2.1 Taciturnity	2.1.1 Nondisclosure of relevant information	Not updating contact information	“Not telling the doctor all your symptoms” (group 7)
		2.1.2 Nonquestioning	Not asking for clarification of confusing information	“Not questioning professionals if instructions are unclear or they do not understand” (group 10)
	2.2 Verbosity	2.2.1 Excessive talk	Not giving the clinician sufficient time to meet concerns	“Telling doctor what I want but not giving much time for him to tell me what he would like” (group 3)
	2.3 Extraneous talk	2.3.1 Irrelevant talk	Trying too hard to recall details	“No relationship with doctor, so just say ’yes‘ to everything” (group 1)
	2.4 Erroneous talk	2.4.1 Inaccurate talk	Contradicting medical advice to family or friends	“Inaccurate/false responses” (group 2)
	2.5 Inarticulateness	2.5.1 Inability to express thoughts clearly	Limited language skills; translation errors.	Inability to describe your sickness” (group 7)
	2.6 Disrespect	2.6.1 Lack of caring	Lack of regard for interests of clinician	“Making 1 appointment for 2 to 4 people” (group 10)
		2.6.2 Discourtesy	Cell phone on during visits	“Not notifying if late or, need to miss, appointments” (group 10)
		2.6.3 Abusiveness	Violent patient	“Being drunk and abusive” (group 6)
	2.7 Artfulness	2.7.1 Dishonesty	Distortion of information given	“Lying about symptoms to jump queue” (group 4)
		2.7.2 Pretense of sickness	Benefits of sick role	“Pretending to be ill to take the day off school” (group 7)
		2.7.3 Manipulation of system	False claims for compensation	“Seeks to manipulate the outflow of information from the medical record” (group 9)
3. Adherence errors	3.1 Collection errors	3.1.1 Prescriptions not redeemed	Prescribed medications not collected from pharmacies	“Only getting medications they can afford for now” (group 10)
	3.2 Storage errors	3.2.1 Storage errors	Storage of medications past expiration date	“Accumulating discontinued medications” (group 9)
	3.3 Self-administration	3.3.1 No treatment	Failure to take recommended treatment	“Running out of medications” (group 10)
		3.3.2 Wrong treatment	Taking discontinued treatment	“Using old medication” (group 6)
		3.3.3 Dosage errors	Excessive dosage	“Doubling up treatment if going away” (group 3)
		3.3.4 Timing errors	Taking medication at incorrect times	“Taking medication in wrong order” (group 11)
		3.3.5 Duration errors	Treatment duration is shorter than recommended	“Stopping too soon” (group 11)
		3.3.6 Hazardous interactions	Interactions of over-the-counter and prescribed treatments	“Mixing pills and alcohol” (group 6)
	3.4 Other delivery errors	3.4.1 Sharing of medication	Sharing medication with family or friends	“Sharing resources with relatives, eg, ‘rescue’ asthma inhalers” (group 10)
Mental errors: proximate determinants
4. Memory errors	4.1 Memory lapses	4.1.1 Forgetfulness	Forgetting to take medication	“Forgetting to collect the medication” (group 11)
		4.1.2 Misrecalling information	Misrecalling when to attend for care	“Turn up at wrong time” (group 1)
5. Mindfulness errors	5.1 Inattention	5.1.1 Failure to notice	Not perceiving	“Not listening to what the doctor says” (group 8)
		5.1.2 Recognize incorrectly	Misreading of symptoms	“Over-reacting to children’s symptoms” (group 4)
	5.2 Overattentiveness	5.2.1 Hypervigilance	Overattentiveness to variations in normal function	“Hyperchondriacal behavior” (group 5)
6. Misjudgments	6.1 Assessment errors	6.1.1 Failure to check	Failure to check on laboratory results	“Not checking pills from chemist” (group 3)
		6.1.2 Failure to monitor	Failure to monitor weight	“Not monitoring blood glucose as recommended” (group 10)
		6.1.3 Failure to record	Failure to keep a patient diary when requested	“Not recording symptoms when asked, or bringing record back as asked” (group 9)
		6.1.4 Wrong assessment	Misreading of instructions	“Stopping medication just because you feel better” (group 1)
	6.2 Unrealistic expectations	6.2.1 Overexpectation of others	Immediate cure	“Expecting the doctor to read their mind” (group 9)
		6.2.2 Overexpectation of self	Self-diagnosis	“Using the Internet for self-diagnosis and self-treatment” (group 10)
		6.2.3 Underexpectation of others	Expected inability of clinician to help	“Having no faith in doctors” (group 8)
		6.2.4 Underexpectation of self	Expected inability of self to cope or share responsibilities	“Inability to cope with new presentations” (group 11)
Memory errors: background determinants
7. Knowledge deficits	7.1 Knowledge errors	7.1.1 Low literacy	Poor language skills	“Inability to read and understand instructions” (group 1)
		7.1.2 Low health literacy	Not knowing the name of medications	“Confusion over brand, shape, color and name (especially when these change” (group 11)
		7.1.3 Low numeracy	Inability to budget	“Not budgeting and not having an emergency fund for medical care” (group 8)
	7.2 Comprehension errors	7.2.1 Lack of understanding	Failure to understand instructions	“Not understanding instructions (eg, re: casts, equipment)” (group 10)
	7.3 Logic errors	7.3.1 Reasoning errors	Considering that a medication imparts absolute protection	“Assuming that must be OK because feeling good” (group 2)
8. Attitudes not conducive to health	8.1 Selfishness	8.3.1 Excessive pride	Reluctance to ask for, or accept help	“Reluctance to ask for help (eg, credit) because of pride” (group 8)
		8.3.2 Dishonesty	Lying	“Lying about symptoms to jump queue” (group 4)
		8.3.3 Self-pity	Feeling a victim	“Feeling self-pity; becoming a victim” (group 1)
		8.3.4 Hedonism	Willingness to drink alcohol inappropriately	“Taking medicines for recreational use (eg, too much insulin to get a high)” (group 11)
	8.2 Self-neglect	8.2.1 Excessive selflessness	Carriage of other people’s burdens	“Putting other people’s needs first” (group 2)
		8.2.2 Lack of self-regard	Shyness at visits	“Forget to love oneself; putting other people before yourself” (group 4)
		8.2.3 Carelessness	Carelessness	“Losing instructions” (group 2)
		8.2.4 Embarrassment	Shame	“Not taking medications because you think your friends might mock you” (group 7)
	8.3 Carelessness	8.4.1 Inattention	Distractedness or absent-mindedness	“Patient distracted—not engaging in the consultation” (group 10)
		8.4.2 Thoughtlessness regarding others	Sharing food and drink while infectious	“Not staying home when feeling sick (so spreading influenza)” (group 8)
		8.4.3 Excessive risk taking	“She’ll be OK” attitude	“Taking risks with your health when sick” (group 5)
		8.4.4 Apathy	Laziness in getting medication	“Noncollection of medicines because of sloth” (group 11)
		8.4.5 Unreliability	Inconsistency in passing on messages	“Inconsistent with medication” (group 3)
	8.5 Distrust	8.5.1 Disbelief	Suspicion of health professionals	“Not believing the doctor” (group 2)
		8.5.2 Fearfulness	Fear of needles	“Staying with an unhelpful doctor because of familiarity and fear of change” (group 1)
		8.5.3 Uncooperativeness	Unwillingness to negotiate	“Refusing to be checked by the doctor” (group 1)
		8.5.4 Pessimism	Feeling of helplessness	“Giving up hope” (group 1)
	8.6 Anger	8.6.1 Impatience	Impatience while waiting for care	“Not having patience while waiting” (group 6)
		8.6.2 Intolerance	Prejudice against doctors with non-English speaking backgrounds	“Stressing out on things that you have forgotten to do” (group 4)
	8.7 Other priorities	8.7.1 Cultural priorities	Mourning takes priority over medication adherence	“Tangi [funeral] disrupts medical/health needs” (group 3)

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The Article in Brief

Patient Error: A Preliminary Taxonomy

Stephen Buetow , and colleagues

Background Most research of medical errors focuses on clinicians and systems. This study proposes a method to account for patients' role in medical errors.

What This Study Found Researchers have developed a three-level system which includes 70 possible types of errors patients might make, alone or with others. Two main groups are action errors, which result from patient behavior, and mental errors, or errors in thought processes.

Implications

This classification system is the first that describes how patients can influence medical errors. Further research, using a variety of methods, is needed to understand more about patient contributions to errors.
Errors are often not created by patients, clinicians, or systems alone, but rather through interactions between these groups. Future work on medical errors should recognize this interdependence.
Correction to Table 2

An error was made in Table 2. Taxonomy of Patient Error in which the entry for Mental errors: background determinants was inadvertently labeled Memory errors: background determinants. A corrected, revised Table 2 is available below.

Files in this Data Supplement:

Corrected Table - PDF file, 3 pages, 474 KB