Table 3.
Reasons for occurrence of significant events and the number of reports identifying these occurrences (191 SEA reports)
| Reasons Given | n | % |
| Individual health care professional 'errors' (e.g. lack of knowledge of practice/hospital protocols, poor clinical task delivery) |
62 | 32.5 |
| Communication (e.g. substandard communication between practice and patient, substandard communication between practice and hospital/out of hours/other agencies) |
58 | 30.4 |
| Patient and relatives (e.g. negative patient behaviour, illness behaviour) |
55 | 28.9 |
| Disease/diagnosis/management (e.g. difficult diagnosis, incomplete history/examination) |
44 | 23.0 |
| Administration (e.g. poor task delivery, ineffective administrative system/protocol) |
32 | 16.8 |
| Medication (e.g. error writing/prescribing/administering (wrong drug dosage/formulation prescribed), no system/protocol to check for out of date emergency tray/bag medicines) |
23 | 12.0 |
| Tests/investigations/results (e.g. no sample tracking/record, delay in checking blood tests results) |
22 | 11.5 |
| Patient records (e.g. failure to check notes adequately, failure to record in notes) |
18 | 9.4 |
| Equipment (e.g. ineffective emergency buzzer system for staff to identify location of emergency, inadequate search facility on computer system) |
13 | 6.8 |
| General practice protocols/systems/guidelines (e.g. no formal protocol for checking BHCGs, no system for emergency bag tracking) |
8 | 4.2 |
| Clinical behaviour (e.g. doctor avoidance of addressing a difficult situation, lack of clinical leadership of patient review) | 8 | 4.2 |
| Reasons for event undetermined | 7 | 3.7 |
| Appointments (e.g. delay in being seen, not enough time with patients) |
6 | 3.1 |
| Visits/external care (e.g. change in out of hrs service, delay in attending house visit) |
3 | 1.6 |
• More than one classification may have been accorded to a single SEA report.