Table 1.

Case Presentations With Criteria for Defining Errors*

Case presentation	Biomedical red flag	Contextual red flag	Criteria for medical error for each variant
			Baseline error	Biomedical error	Contextual error
Man, aged 43 y,  with recent  persistent asthma  symptoms despite  being prescribed a  low dose of a high- cost, brand-name,  inhaled  glucocorticoid	“Sometimes I  wake up wheezing  or coughing at  night.”	“Things have been  tough since I lost  my job.”	No intervention to  address inadequately  controlled asthma  symptoms.	Not treated for  gastroesophageal  reflux despite four  symptoms of the  condition	Patient advised to  increase dosage of  current medications  without consideration of  cost, despite four  indications that he  cannot afford them
Woman, aged 47 y,  presenting for pre- operative  assessment of hip  replacement,  reports mild  hypertension and  overweight	Mentions recent  weight gain,  constipation, and  heavy menses.	“I’m looking  forward to the  surgery so I can  take better care of  my son.”	No discussion of  possible risk factors  of surgery	Patient not evaluated  for hypothyroidism  despite four  symptoms of the  condition	Physician raises no  concerns about surgery,  despite patient’s first  priority being to care for  an adult child who has  end-stage muscular  dystrophy and depends  on her fully
Diabetic man, aged  59 y, presents with  two presyncopal  episodes after  previous doctor  increased insulin  dosage	“Felt some  pounding in my  chest when it  happened.”	Confuses dosages  and says, “It’s  hard for me to  keep numbers  straight.”	No adjustment of  insulin dosing or  discussion of  changes in diet to  prevent  hypoglycemia	No electrocardiography,  event monitor, or stress  test ordered in patient  with four symptoms of  arrhythmia	No discussion of or plan  to address obstacles to  self-care in patient with  four indications of  learning or cognitive  disability that impairs  his capacity to correctly  dose his medication  since he left a  community where he  had assistance
Man, aged 72 y,  with unexplained  weight loss	Shows signs of  being depressed.	Seems  impoverished and  possibly  homeless.	No evaluation for  cancer in patient with  unexplained weight  loss, and depression  and malnutrition  ruled out.	No treatment or  referral for depression  in patient with four  symptoms of  depression	No discussion of or plan  to address malnutrition  in patient who provides  four indications of  inadequate access to  food

*Presentations and red flags were the same for all variants of a case. The biomedical and contextual variant (not shown) was always a combination of the biomedical and contextual variants.

(reprinted with permission, Ann Int Med 153(2):W–29)