Table 3.

Problems identified and contributory factors in medicine

Stage in process of care	Principal problems identified	Contributory factors
Diagnosis	Incorrect or delayed diagnosis	Inadequate involvement of experienced clinicians
Pre-procedure assessment and care	Failure to provide prophylaxis	Lack of protocols
Invasive procedures	e.g. insertion of central venous lines	Insufficiently experienced ward clinical staff
Ward management	Poor management of complex disorders	Lack of facilities and/or experienced staff for high dependency care
	Pressure sores	Failure to identify at-risk patients and to undertake prophylactic measures
Use of drugs and intravenous fluids	Problems in prescribing	Insufficient care in prescribing; lack of computer support
	Confusing prescription charts
Discharge procedures	Patient's medical condition not adequately stabilized	Failure to assess condition 24 h before discharge
	Patient has insufficient knowledge of condition	Failure to ‘educate’ the patient
	Poor communication with GP/community services	Failure to provide adequate ‘package for home care’
		No protocol for discharge