Table 2.
Summary of significant events.
| Category | n | ‘Red’ | Detail of serious/life-threatening events |
|---|---|---|---|
| Death occurring in practice premises | 0 | 0 | – |
| New cancer diagnosis | 32 | 1 | Delayed diagnosis of rectal carcinoma |
| Death where terminal care took place at home | 15 | 1 | Possibly an avoidable death from malignant melanoma |
| Patient complaint | 17 | 0 | – |
| Suicide | 3 | 1 | Suicide of patient referred urgently to mental health team |
| Section under Mental Health Act | 8 | 1 | Violent psychotic patient absconded from section on ward |
| Other administrative | 95 | 2 | Delayed diagnosis of ectopic due to unlabelled sample |
| New diabetic moves away before diagnosis given | |||
| Prescribing-related events | 46 | 4 | Gastrointestinal (GI) bleed from warfarin and Cox II drug reaction |
| Incorrect phenytoin dose prescription | |||
| The wrong dose of warfarin dispensed | |||
| Two different hospitals gave contra-indicated drugs to one patient leading to GI bleed | |||
| Nursing-related events | 23 | 3 | Failure to act urgently in new diagnosis of diabetic child |
| Unwitting duplication of oral hypoglycaemic drugs in nursing home | |||
| Failure to hydrate a patient with dementia in nursing home | |||
| Other medical | 70 | 8 | Refusal of readmission when aneurysm patient deteriorated |
| Absent emergency drugs in surgery | |||
| Inappropriate management of chest pain | |||
| Missed diabetes diagnosis in a child | |||
| Anti-depressant overdose | |||
| Unprepared for childhood immunisation anaphylaxis | |||
| Emergency oxygen unavailable | |||
| Discharge of dying patient without notification to GP or family | |||
| Other | 28 | 1 | Assault on GP |
| Total | 337 | 22 | – |