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.