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 |