Table 2.
Number and types of problems identified in each segment of care (numbers in square brackets indicate those deemed probably preventable)
| Stage of care | Medicine | Surgery | Orthopaedics | Total | |||
|---|---|---|---|---|---|---|---|
| Diagnosis | Missed heart failure (2) | 2 [2] | Incorrect assessment abdominal pain (2) | 2 [2] | Missed fracture | 1 [1] | 5[5] |
| Preop assess/care | ERCP—prophylactic antibiotics not given | Urinary catheter infection (2) | Missed hypokalaemia | 6 [5] | |||
| 1 [1] | Failure to give anticoagulant prophylaxis | 1 [1] | |||||
| Failure to assess chest disease | 4[3] | ||||||
| Anaesthesia | Problems with intubation (2) | Difficult intubation | 6 [1] | ||||
| Bronchospasm during surgery | Propofol seizure | ||||||
| Propofol seizure | 4 [12] | 2 [0] | |||||
| Operation/procedure | CV catheter infection (2) | Surgery not completely effective (2) | Poor result following surgery (5) | 40 [9] | |||
| CV catheter haematoma | Failure in internal suturing (2) | Wound infection (6) | |||||
| Infection post urinary catheter | 4[3] | Wound dehiscence (3) | Haematoma (3) | ||||
| Wound infection (8) | Delayed inflammation after joint replacement | ||||||
| Postop intestinal obstruction/dysfunction (2) | |||||||
| Post-cystoscopy prostatitis | 15 [2] | ||||||
| Central line infection | |||||||
| Postop bleeding | |||||||
| Postop dizzy turn | 21 [4] | ||||||
| Ward management | Pressure areas (3) | Pressure areas (4) | Pressures areas (3) | 30 [15] | |||
| Cardiac arrest | Care of chest (3) | Care of chest (2) | |||||
| Alcoholic organ failure (2) | Care of urinary catheter (2) | Multiple problems in the elderly (4) | |||||
| Abdominal infection | 9 [5] | Fall in ward (3, 2#NOF) | |||||
| Weight loss/dehydration | 8 [5] | Care of food and fluid intake | 13 [5] | ||||
| Drug/i.v. fluid | Drug—inappropriate dose/treatment (3) | Drug—inappropriate dose/treatment | Drug reaction | 17 [9] | |||
| Drug reaction | Drug side-effects (2) | Drug side-effect (2) | |||||
| Drug interaction | Fluid overload (2) | 3 [1] | |||||
| Drug side-effects (3) | 5 [3] | ||||||
| Over-transfusion | 9[5] | ||||||
| Discharge | Inadequate assessment—readmitted (4) | Repair inguinal hernia not assessed—developed hydrocele | Inadequate assessment—readmitted | 14 [10] | |||
| Without plan (asthma)—readmitted | Inadequate home support—readmitted (4, 2 with #NOF) | ||||||
| Without medication—readmitted | 6 [4] | 1 [0] | Delayed discharge (waiting placement) (2) | 7[6] | |||
| Total | 30[20] | 46 [18] | 42 [16] | 118 [54] | |||
| ERCP=endoscopic retrograde cholangiopancreatography; CV catheter=central venous catheter; #NOF=fractured neck of femur; i.v.=intravenous | |||||||