Table 2.

Examples of incident types with patient harm outcome

Incident extract examples, minor edits made for clarity	Severity [16]
Medication provision
1. ‘Patient was prescribed penicillin and was allergic to it. Computer did not flash up allergic reaction when it was prescribed. System failed. Patient had an allergic reaction to drug.’	Moderate
2. ‘Insulin-dependent diabetic with dementia discharged following admission for hypoglycaemic episode. DN requested to monitor blood sugar/insulin. Dose of insulin on transfer of care letter different to dose on discharge summary given to patient. Also metformin stopped and patient/husband not informed so had been given. Ward contacted to verify correct regime.’	Unknown
3. ‘Patient has levothyroxine 100 mcg on repeat prescribing. Levothyroxine 25 mcg dispensed incorrectly on [date]. Patient attended surgery [three months later]—symptomatic’	Low
4. ‘Patient discharged on anticoagulant therapy warfarin 4 mg once daily—previously on 1 mg prior to admission. No INR done after discharge. Bruising, haematoma right thigh & looking very pale. Readmitted to hospital and died.’	Death
5. ‘Patient was given prescription for amoxicillin. Daughter telephoned the surgery to ask why her mother had been prescribed a medication that she was allergic to. She also wanted to make the practice aware of this fact.’	No harm
Communication processes
6. ‘The patient was suffering from AF. The GP visited the patient, prescribed warfarin and documented in the notes that the patient should be referred to the DN to be monitored. The documentation in the notes failed to be communicated which meant that the patient was not monitored for 3 weeks. The patient became ill and was admitted to hospital. Subsequently the patient died.’	Death
7. ‘Urgent cancer referral fax to hospital. Received receipt with message saying, ‘Consultant has own fax machine and number in his room—Please use it in the future.’ This goes against telephone numbers issued from LHB.’	Unknown
8. ‘Housebound patient seen in Outpatients. Neighbour came to GP surgery saying medication had been altered but no notification of this to GP. Phoned Consultants Secretary who stated his letters are one month behind and she has been told by ‘the management’ that letters must be sent out in strict date order and she cannot help. GP has had to do prescription based on information given by neighbour.’	Unknown
9. ‘Recent admission, new medications added. Medication list on discharge letter did not include some of the patient's previous regular medications so GP assumed they had been discontinued by hospital. 1 month later, patient had CVA. Very hypertensive on admission. Subsequently discovered that hospital had intended her to continue antihypertensive medication, even though omitted from discharge medication list.’	Severe
10. ‘Poor interim discharge notification for patient. Inpatient [for one month] but no diagnosis etc…’	Unknown
Clinical decision-making and investigative processes
11. ‘Blood test from GP was abnormal. Advice was given on test report to perform other important tests to evaluate/confirm diagnosis of myeloma. Three months later the patient presented in established renal failure. Diagnosis of myeloma made on day of admission. Patient died on ITU 4 days later. This death was totally avoidable.’	Death
12. ‘Elderly male patient 80 yrs old attended surgery with recent but not current chest pain. Given ECG which was mis-read. Patient advised to return home but should have been sent to hospital urgently. Patient died at home from heart attack within 24–48 hrs.’	Death
13. ‘Patient blood test showed Hb 8.1, sudden drop. Result seen by colleague and signed “to keep appointment in 2 weeks” At appointment blood result NOT discussed. 5 weeks after blood test patient returned short of breath and symptomatic. Required immediate treatment and urgent referral.’	Severe
14. ‘A working diagnosis of diverticulitis was made at home visit and treatment prescribed. Patient was admitted to hospital and died from a ruptured abdominal aortic aneurysm.’	Death
Equipment provision
15. ‘Profiling bed and air flow mattress were ordered for same day delivery. Didn't arrive for 3 days. By this time the vulnerable patient had developed pressure sores on several parts of her body and the skin was broken on her hip requiring a dressing.’	Moderate
Access to healthcare provider
16. ‘GP home visit requested for terminally ill patient at 20:30 pm. Dr. did not visit until 01:40 am. Patient died at 02:30 hrs’	Unknown

Key: DN, district nurse; OD, once daily; INR, international normalised ratio; AF, atrial fibrillation; LHB, local health board; GP, general practitioner; CVA, cerebrovascular accident; ITU, intensive care unit; Hb, Haemoglobin.