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. 2007 Oct;16(5):369–377. doi: 10.1136/qshc.2005.016964

Table 5 Examples of preventable adverse events identified during hospitalisation.

Case no. Clinical description Preventability score*
1 Inhalation pneumopathy during anaesthetic induction for oesophageal diverticulum in a 48‐year‐old man 4
2 Pneumothorax in a 51‐year‐old man hospitalised for pneumonectomy (aspergillosis on tubercular sequelae) occurring during subclavian catheterisation 5
3 Stomach lesion during nephrectomy via coelioscopy, requiring subsequent open surgery in a 59‐year‐old woman 4
4 Perforation of the colon during colonoscopy in a 73‐year‐old man 4
5 Dissatisfaction expressed by a 57‐year‐old patient hospitalised for endoscopic retrograde cholangiopancreatography under general anaesthetic, which was delayed on account of a leak in the endoscope discovered once the patient had been anaesthetised 6
6 A 79‐year‐old patient dissatisfied after discharge was delayed; patient hospitalised for spontaneous haematoma of the left intracranial haemorrhage, waited 25 days for a control scan which was never actually performed. Communication problem between the admitting and radiology departments 4
7 Lumbar pain in connection with second lumbar vertebra fracture not diagnosed in emergency unit, delay in diagnosis and corset fitted in a 20‐year‐old man 4
8 A 96‐year‐old woman hospitalised for acute sigmoiditis and varicose ulcer treatment had intense systematic pain during care procedures despite preventive treatment (15 mg morphine administered subcutaneously) 4

1  =  virtually no evidence for preventability; 2  =  slight to modest evidence; 3  =  preventability not quite likely; 4  =  preventability more likely than not; 5  =  strong evidence; 6  =  virtually certain evidence.