Table 4.

Selection of reported incidents

Discipline	Description of incident	Causes mentioned
Internal medicine	Unnecessarily high glucose level.	- Notification by supporting personnel was too late (attending resident was supposed to be called by telephone about this) - Very busy at department
Multiple	Preventable infections.	- Health care workers do not always wash their hands before touching another patient - Laziness - Time pressure - Unaware of seriousness of the consequences
Gynecology	Delayed delivery of a child in foetal need.	- Suction pump out of order (probably caused by bump to door pillar) - Health care worker's ignorance of slurp sounds made by suction pump - Insufficient checking of the suction pump
Revalidation	Needle (with cover) found in bed with patient.	- Incompetent laboratory assistant - Patient also had not noticed the needle - Very busy at department
Emergency medicine	Patient needed plaster bandage, but was sent home without.	- Miscommunication between physician and nurse - Nurse followed own policy
Pediatrics	Patient needed isolated room, but was admitted to a room with multiple beds. The other beds in the room were kept empty.	- There were no isolated rooms available - It was late in the evening
Anesthesia	Unknown amount of local anesthetic was given to patient during spinal anesthesia.	- Hastiness - Connection between spinal needle and sprayer was insufficient and fell apart
Orthopedics	Decubitus ulcer.	- Decubitus prevention plan not followed by nurses - Busy nightshift
General surgery	Patient was kept sober all day and was prepared for the operation room, but the operation was not performed that day.	- Operation was not registered on operating list - Unclear description in patient's chart - Unclear treatment policy - Order was not checked - Miscommunication between health care workers