Table 4.

Cases illustrating system issues and processes implemented to mitigate recurrence of the issue

System issue	Case example	Processes implemented to improve quality
Goals of care were not discussed or the discussion was inadequate	70-year-old man with metastatic cancer of unknown primary who was receiving chemotherapy was admitted for febrile neutropenia. He was treated and then discharged to a continuing care hospital because of generalised weakness caused by cancer, chemotherapy and his infection. A week later, he was seen in clinic by the oncologist who noted the patient was declining. The following day the patient returned to hospital with progressive generalised weakness. He said that end-of-life care had never been discussed with him and he did not know his cancer was terminal. There was no record of discussions about end-of-life care in any documentation. He died the following day.	Palliative-care physicians have been incorporated into the cancer clinic. They are available to meet with patients and discuss goals of care and prognosis. Also, a standardised serious illness conversation guide is being implemented on medicine wards so that patients have more opportunities to discuss their prognosis and their wishes for care.
Delay in diagnosis or failure to achieve a diagnosis	75-year-old woman with a history of severe COPD requiring 2 L of home oxygen and severe aortic stenosis presented to ER with 3 days of diffuse abdominal pain, rapid atrial fibrillation and hypotension. An abdominal XR on admission showed right mural thickening of the colon concerning for ischaemic bowel. No treatment was initiated. 24 h later, a CT abdomen was performed showing pancolitis. 48 h into the admission, a urine culture came back positive and the patient was started on antibiotics for the first time. On day 3 of admission, the patient had worsening hypotension and tachycardia. The patient was transferred to intensive care unit and general surgery was consulted for possible ischaemic colitis. The patient died from refractory shock.	A sepsis protocol has been implemented in ER so that patients with signs of septic shock receive broad-spectrum antibiotics early.
Inappropriate delay in transfer to hospice or long-term care and developed pressure ulcer in hospital	74-year-old female with metastatic pancreatic cancer that was progressing on third line chemotherapy presented to ER with constipation and abdominal pain. The constipation was treated and symptoms were controlled. Further chemotherapy was forgone because of progression of disease. The patient remained in hospital for 2 weeks, developed a pressure sore and died in hospital. No application was put in for hospice care.	We have increased collaboration with palliative-care physicians for discharge planning. To prevent pressure sores, we have implemented hourly rounding by all ward nurses.

COPD, chronic obstructive pulmonary disease; ER, emergency room; XR, X-ray.